THE LANCET, Novemper 24, 1888.

Introductory Address

ON THE

STUDY AND PRACTICE OF SURGERY.

Delivered to the Class of Systematic Surgery, Owens College, Mancheea October 3rd, 1888,

By ARTHUR W. HARE, M.B., F.R.C.S.E., &c.,

PROFESSOR OF SURGERY IN THE COLLEGE.

Mr. PRINCIPAL AND GENTLEMEN,—An introductory Jecture is, in the nature of things, an embarrassing occasion ; it involves a division of interest and attention that precludes any great possibility of deriving organic satisfaction from it. It may, I think, be accurately likened to ‘ grace before meat,” where, as you may be aware, human nature is apt to be racked by conflicting emotions: the earnest wish to enter on the feast with hallowed feelings; the no less keen desire to obtain a surreptitious glance at the menu card. This is but an illustration of the two-sided character of our mature, which labours so cheerfully under that paradoxical strabismus that directs ‘one eye on earth, the other fixed on heaven.” But I can assure you, gentlemen, we are not here assembled to lament over the foibles of our common mature, but rather to accept the position, and, it may be, even to turn it to profit. For on the analogy already weferred to I think we can base the order of what is to follow—namely, that in discussing the ‘‘ Study and Practice «of Surgery” we may naturally direct our thonghts to two

ints: firstly, in what frame of mind can we fitly engage an this study? and, my | what is really useful and valuable for us to uire by it? I cannot attempt to emulate the intellect recision of the proverbial Scottish divine in a omg the headings of my address, but I have acquired some slight tinge of his method during a ten

ears’ residence in his delightful and hospitable land, and I ope, therefore, to be able to keep the two parts of my subject carefully distinct from one another, and to present each to you in turn in a not inappropriate manner. THE STUDY OF SURGERY.

I suppose, if the opinions of all present in this room were taken on the point, we might find an extraordinary difference of belief as to what study means ; and even more, if we took a similar census of opinion among all the teachers and students of surgery throughout the kingdom, I believe we should find strange vagaries, if not in theory, at least in the _— interpretation of the question. It is all very well

or me to come down here to-day, and to say to you, «Gentlemen, we are met to study surgery together”; but it is quite open for you to ask me, ‘‘ What do you mean b study?” and ‘‘ What do you mean by surgery?” and it is my duty, as it is my present purpose, to try to answer both questions.

Study.—Now the process of study implies brain activity : that is, the presence of brain tissue, and an active will behind it to make it work. So far we are allright. I see defore me the evidences of both in large measure. But a far more important question at once confronts us in regard to how these sonnel faculties are to be employed in this room. What is to be the relation of teacher and student in carrying on the process of — Se ? The _— of study is in many aspects wonderfully like that of nutrition; and you will forgive me if I try to illustrate my meaning by describing a lecture as an intellectual feast. Of course, I am not now referring to individual instances; I am attempting to illus- trate a general principle. At a feast, usually one person, the chef, is responsible for the appearance of the viands, the others for their disappearance. So, in a lecture, the lecturer must produce the material for discussion. Now, I want to bring out the fact that a well-ordered lecture cor- responds precisely to a well-ordered feast in certain very essential iculars. <A well-appointed feast is not one in which all the courses are served simultaneously, where the

ests must pounce pell-mell on all sorts of incompatibles in their desperate efforts to initiate the process of nutrition. ~~ a mélée could only delight a savage. Just such a

oO. 2404.

disaster, intellectually speaking, attends a lecture composed of disarranged eae On the other hand, a feast might be composed of simples cireumspectly chosen; and even, thanks to the genius of Sir William Roberts, carefully peptonised, creatised, or already half-digested. The guests, probably somewhat languid and delicate, would each take his due proportion with meekness, and would depart peacefully, relieved even of the fatigue of conducting his own digestion. Some lectures and a good deal of ‘‘ coach- ing” are, I fear, very much like that, and are only fit for intellectual dyspeptics. But there is a very happy middle course between such extremes in the matter of feasts, where gustatory and ae instincts, awakened by pre- liminary stimuiation, nobly acquit themselves upon the piece de résistance, and maintain a cheerful activity to the very end. Precisely analogous to this caleulated effort of the chef should be the labours of the lecturer. The origina- tion of conceptions based on well-ascertained facts, their arrangement in proper sequence under the searching scrutiny of a logical analysis, the clothing of such concep- tions in a suitable guise of illustrative detail, and their expression in lucid and appropriate language—such are the objects which the lecturer must have in view in carrying out his share in what I conceive to be study.

And what is the part the student must play in the process of study in the lecture room? Is it to na mark, learn, and inwardly digest” the sayings of the said teacher? In a sense it is; but in no spirit of too ready acquiescence. I maintain that unless a teacher gives his students grounds on which they may reason as to the results propounded he is at most but half what a teacher should be. And itis this process of employing the reasoning faculty in following the lecturer in his statements, or in disagreeing with him, that constitutes the chief duty of the student in the study of the lecture room. The teacher’s facts are, for the most t, common property in the text-books. His function in a teachin Institution is surely not that of pouring forth a text-boo of not very interesting information to aching ears and feverishly hurrying pens. For him is reserved, if he com-

rehend his mission aright, the higher function of stimu- fating his fellow men to think for themselves, to prove all things, and to hold fast that which is good. That, I take it, is the true spirit of the lecture room. No bare statement of facts, with implicit, unwavering acceptance ; no desultory titillation of a wayward fancy or a transient interest ; but an earnest, a painstaking, and, above all, an unbiased discussion of facts, and the laws they support and illustrate. What honour and a et of p are in the sphere of morals, such are independence and spontaneity in that of intellect. Beware, gentlemen, above all things, that you do not suffer the scholastic influences of this institution to deprive you of your individuality or to rob you of your natural faculty to originate. ou may depend upon it that a calm thinker like Cicero appreciated the importance of this danger in the educational system of his own day, when he said, speaking of theology, that ‘the very authority of those who teach often stands in the way of those who are learning.” I cannot help thinking that Goethe entertained a similar view, and that it was with a cynical desire to expose the true nature of such teaching that he places in the mouth of Mephistopheles sentiments the reverse of Cicero’s opinion. Whether Goethe had any such intention I must leave it for others to decide, but certain it is there is something of a familiar and modern feeling about this part of ‘‘ Faust,” so faithfully does it portray institutions still extant. The Evil One, dressed in the professorial gown of Dr. Faustus, thus addresses to an ingenuous undergraduate a subtilely inter- woven tissue of good and evil counsel :— *« But first be sure, the next half year At every lecture to appear. Five hours each day for ~- 74 Be there the moment the bells Be sure beforehand to prepare, ve every : Watch lest the teac er go beyond The matter written in his book. Then, as you write his dictates, look That you take down verbatim all And every sentence he lets fall, As though each sentence Scripture were That comes from a professor's chair !”

Gentlemen, did you ever hear advice resembling that? It

may have been a unique experience of my own, or it may

have been a dream; but I cannot help thinking that x

| | | } |

1006 THe Lancet,) MR. A. W. HARE: THE STUDY AND PRACTICE OF SURGERY.

[Nov. 24, 1888.

in some modern university, British or foreign, I have had such an experience, and have been told to trust to nothing but the verbatim notes of the lectures I was about to attend; yes, and, if I mistake not, my adviser was dressed in a professor's wn. But at that time I had not read Goethe’s ‘‘ Faust,” and could not be expected to know then what I afterwards came to ise. While we are speaking of note-taking, you may wish to know my view of the matter. To become a verbatim reporter 1s, to my mind, somewhat beneath the dignity of an aspirant to scientific and professional honours. Nor is this my only objection to it as a matter of principle. Verbatim note-taking implies a vast expenditure of ene in recording a teacher’s thoughts in his own words; and the results at the end of the session are, perchance, an attack of writer's palsy, and almost certainly a sad and oppressed heart, that can hardly be cheered up by the possession of a manuscript text-book, more or less legible, and nearly as valuable, though not so easy to read, as a Well-bound and well-printed thirty-shilling volume on the same subject. I ssess such manuscript literature myself, but the pride one might feel in such a possession is tinged with a certain pathos, just as one a look back wonderingly on some generous but unpractical impulse of early life, which led to great but misdirected effort. But was it a generous impulse, after all, that led one to verbatim note-taking? as it, indeed, the intense anxiety to lose no grain of the golden wisdom of the teacher? Or was it not the thought of coming trial in which the information thus gained would be our only available support? If the last is in any sense true, our hurried pens were driven by Black Care and Craven Fear, and not by the enthusiasm of a healthy emulation. Each added line of our manuscript was but additional inscription on the tombstone of our originality. For this mass of ink and paper is the expression of no individual thought of our own. e have merely acted the part of Mr. Maskelyne’s wonderful automata; we have performed an intricate pro- cess, and we have performed it well; and, so long as the teacher and examiner guide us, we may be able to do won- derful works ; but when they cease to pull our wires, and we are left to ourselves, we are ted 4 to be a singularly perfect and exquisitely finished piece of mechanism, as indeed their parting testimonials assure us, but for all that we are motionless and dumb. 1t is years in many cases, after the man has left off coming on his daily round to wind us up, before we can regain the power he stole from us of doing it for ourselves. But, gentlemen, do not rush rash] to the opposite extreme, and say that, if note-taking has this effect, we will none of it! I should be very sorry to think that any course of lectures exists anywhere at which it is not highly advisable to take notes. But do so wisely, not too well. As I urged you to think your own thoughts in the lecture room, so I now beseech you to take your own notes. You must strive to be true observers, and, as Sir James Paget has eloquently urged, note-taking observers. ‘ But how can we observe in the lecture-room ?” you may ask. The lecturer, with the aid of verbal and pictorial scenery, rehearses before you scenes from the drama of Disease, and, as development follows development towards the happy dénouement or the final catastrophe, you will do well, while not omitting to enjoy the interest of the piece, to note its leading features shortly, in your own words, employing your own brain cells in so doing, and in such a way that future reference to your note-book will recall to mind the thoughts that were awakened in it by what you saw and heard. Compare this method with the other, and I think you will perceive its deeper wisdom and its truer safety. As a note-taking observer, you are on the outlook for the true proportion between events; you detect the hitch at once if omissions are made, and will supply the missing factors. The verbatim note-taker, on the other hand, has no time to think of this. He commits all facts alike laboriously to paper, regardless of their relative values, oblivious of possible omissions. If he is taking notes on ‘*Hanilet,” he only experiences a sense of relief if the long apostrophes of the Prince of Denmark are omitted; while you, seandalised and horrified at the enormity, procure a ‘*Shakspeare” and detect the truth. The object Ss teaching is not to produce a mental repletion, but rather to stimulate the intellectual ee and educate the intellectual palate in the selection of those things that are useful and meet to be digested. Montaigne complains quaintly, if not very elegantly, 300 years ago, that “teachers are wont to be continually drumming into our ears, as if they were pouring

into a funnel; while our part is to repeat what they have told us. It is a proof that we have not digested our food if we throw it up just as we swallowed it; the stomach has not done its work, unless it has chan the form and the state of what we gave it to deal with.” If that were all, gentlemen, that was to be accomplished in the lecture room, —if it were merely for the hearer to hear and be able to repeat what the lecturer tells him, there were no object in bringing with you your intellectual activities and power of individual judgment; it were better could each of you be represented by the vocalising sensitive strip of the perfected phonograph, which would in that case complete the process to the satisfaction of the examiner and of all concerned. Not only is such a system in itself useless, it is positively deleterious; for, as my distinguished predecessor in this chair has said—summing up, in fact, the whole of my argu- ment, as it were, in a nutshell,—“ by trying to take in too much, to tax the memory rather than exercise the judgment, the effort so exhausts the mental —_— that, although tempo success may be achieved and the prize be won, all taste for the subject is destroyed, and the man no longer cultivates the early aptitude he may have displayed.” For knowledge acquired in that unreasoning way 1s not worth of the name. The only knewledge that is real is that whi our reason has accepted, which has become a part of our instinctive perceptions, and therefore forms a sound basis for our individual actions. The true spirit in which to proceed, is that of the old philosopher, who wrote— “ Myself, when , did erly frequent

Doctor and ond heard great angument.

With them the seed of wisdom did I sow,

And with my own hand wrought to make it grow.” The last line is specially to the point. Go to the lecture room to learn, not to be taught. By all means make use of the doctor’s and saint’s experience as regards the method, but take your own share in sowing the seeds of wisdom, for in your own hands only must rest the subsequent cultivation. A man would look with contemptuous astonishment on the tutor who disinterestedly offered to sow all his wild oats for him; but he does not always see that it is even more important for him to sow for himself the ‘‘seed by which a man may live.” Such, I take it, is the spirit in which all study should be conducted.

We must now inquire what is really worth our attention in the study of surgery. All knowledge is not of equ value to men whose sphere in life is one of action, not of contemplative theorising. In our own case this is pre- eminently true ; and it is therefore specially important for us to settle what is really worth knowing, and what worth ‘knowing about,” as Mr. Teale puts it. Herbert Spencer, in his valuable essay on education, describes three qualities of knowledge: that which is intrinsically valuable, that which has a quasi-intrinsic value, and that of which the value is merely conventional. In stud ing surgery we shall be wise if we can eliminate knowledge of the last kind, or reduce it till it is actually an irreducible minimum ; while to knowledge of quasi-intrinsic value we should attempt to give adequate limitation, reserving the bulk of our time and energy for the cultivation of that which is intrinsically valuable. Now surgery is, of all others, the most practical of themedical sciences, and the knowledge of it which is really intrinsically valuable is that which bears directly upon its practice among the community. What is wanted is an exact and scientific knowledge of the facts that underlie the diseased processes with which we have to deal from day to day, and a clear anlemtaneiig the principles on which our treatment must be based. We must not be content to ise a disease, to call it by some con- ventional. name, and treat it in the fashionable way; we must strive to know in what the essence of the disease consists, and in what manner the remedies employed are effective in neutralising diseased action. Unless we have such knowledge, our professional position is an empty shadow that is not the thing it appears to be; and our treat- ment of disease degenerates into simple and unenlightened rule of thumb. Shall we be content to allow our life work to become mere mechanical guinea-grinding, when it may be an enthralling and perennial interest? Assuredly not! And no more shall we think of permitting our study of surgery to be a dreary grind of uninteresting facts, when it offers us all the inducements of an intellectual ursued. Such knowledge is intrinsi- e highest degree ; it is the very light

time, if fitl valuable in

MR. A. W. HARE: THE STUDY AND PRACTICE OF SURGERY. [Nov. 24, 1888. 1007

THE LANCET,] = which we can walk safely and in comfort alon path of professional activity. Without it we shoul grope blindly and miserably in a darkness that can be felt, and painfully felt ; for can you imagine any more painful sensation than to fumble and stumble and do harm through lack of knowledge that might have been ours had we not criminally neglected the opportunities of acquiring it? To a conscientious man, one moment’s experience of such a conviction of remorse nay mar @ year’s happiness ; its con- stant presence that of a lifetime. In studying surgery, therefore, we must give the first and largest place to this knowledge of intrinsic value, directly based on facts ; and we must make it once for all our own by real — We cannot acquire it by any rapid process. It cannot, from its nature, be condensed and summarised, and finally put into mnemonics to help us at examination times. It must honestly and squarely looked in the face, and resolutely and systematically conquered. We must find some place also for knowledge of quasi-intrinsic value. What I understand b that is—all the by-ways and oe that intersect the hig road of surgical study, many of them leading to pleasant and interesting resting places, from which one gets a new view of the route the main road is taking. Only, one must not venture too far into them, for fear of losing sight of what is really more important to our pro hese diversions are the many side-issues and problems of a theoretical mature which encounter us at every step of a course of surgical teaching. They will add much to the interest of the study if we are warned in time not to follow them too far. Such speculations, based on facts insufficient to warrant definite conclusions, are often very seductive, but we must beware of giving them an unquestioning accept- ance, however well devised and in however delightful a garb they may be presented. But of facts themselves we need have no fear. We cannot safely mould them to fit eur theories ; we must make our theories coincide with them, at whatever cost. They are stubborn, immovable stones in the highway of truth, and we must carefully adapt our vehicles of thought to run evenly over their irregular surfaces, or they will hurl us, along with other hobby-riding heroes, into the ditch of error. You may be inclined to smile at my vision of what might be if we forsook the régime of free and unrestricted inquiry ; but I may, in turn, remind you that our art lay crippled for a thousand years, making no advance on Galen’s position, if not indeed re ing, through this very fault of implicit intellectual obedience to doctrinal formulas instead of to fact, this mental slavery, this strangling of man’s rational conscience that would ever arise and ask the question “Why?” Well, we have changed all that; we have esca at last from the tyranny of scholastic dogma and entered on a new ee of individual freedom of thought. And here I am in a little difficulty. I should like to call our present era that of universal suffrage in constructive thought, as it undoubtedly is in criticism. But I cannot escape the un- comfortable conviction that, having forsaken the bondage of a blind adherence to dogma, we have substituted for it a sweet reasonableness that by comparison certainly seems rfect freedom, yet renders us for the most part the facile llowers of fashion. And fashion changes. The mode to-day is the most newly-exploded fallacy of to-morrow. The surgical teacher of the present day, who follows—as he is in duty bound to follow—the strict canon of current orthodoxy in his teaching, .is therefore in a_ painful position. He must daily take his bearings afresh (‘sich orientiren,” as the Germans aptly put it). He retires to bed each night under a darker cloud than even the condemned criminal, for on the morrow he may require not a substitute for his head as a whole, but, horribile dictu! an entirely new suite of internal furnishin for the same. Now fashion is by no means to be condemned ; it is the channel through which flows the ever-advancin current of progress. Yet the knowledge of the poner | fashion of the moment is knowledge of quasi-intrinsic value, and will not compare in importance with that of the broad principles that underlie the relations of health and disease, nor of the broad practical systems by which we combat the one and conserve the other. But at times we are in danger of losing sight of these distinctions in our course of stu i at times particularly when our better judgment is apt to warped by some apparently as catastrophe. Then it is that study, properly so called, tends to give place to “‘eram”; and then that the cramming system is itself seen in its least desirable and least discriminative form.

In regard to this matter, I wish for a moment to take a simile from political history. It is ancient political history, therefore no on the subject. There was once a party in country which many irreverent aowaneges of the d called the ‘ Jingo” y- It was said by the “ anti- Jingoes” that the “Jingoes” suffered from a type of quotidian political ague, the cold trembling s' and the hot stage recurring and alternating with frightful rapidity. I cannot say whether there was any more truth in this than in very many other political statements; but what I wish to point out to you is that there are a number of examina- tion ‘‘Jingoes” constantly in existence, who do a great deal of harm by seeing, and making others see, systems of examination through the distorting medium of a fevered imagination. However calmly we may have schooled our- selves to a reasonable view of the matter, we are all apt to be somewhat affected with the complaint just before an examination. The cold stage is horrible; one can only shiver and do little else. Then the hot stage is u one, and drives one to do all sorts of unnecessary thin on the advice of other sufferers worse than oneself. The judgment becomes temporarily warped as to what is important and what is absolutely unimportant, and one comes to resemble closely those patients described by Wendell Holmes, who dieted, much to their friends’ surprise, | kles and pencils, and chalk and coals.

In our own case, the “friends” in question are the ex- aminers, who must often be much more surprised at the

ueer things (such for instance as ‘‘ examination tips”) that they do find in our heads when they make the sectio, than at the many things, expected and hoped for, which they do not find. Well, gentlemen, that is a little malady we are apt to suffer from ourselves, and it is — appro-

riate that our charitable sympathy should begin at

ome with ourselves. But it is a question, I think, whether a grain or two of sympathy may not be needed elsewhere. Do examination s never suffer in any way, similar or dissimilar? Do they really never ask us to acquire rather out-of-the-way information, that we do wisely to forget as soon as its tery ww’ I use is over, and that may perhaps have somewhat largely occupied our minds at the expense of knowledge of ter practical moment? Into this ques- tion as a whole I need not enter further here; for I have reason to know that able representatives of our own a of other learned professions in high places are now giving this matter very serious consideration, and I think we may hope that the outcome of their discussions will be a diminu- tion of the evil, and a further development of what is in present educational — But to one point I shall venture to refer. In the study of the world around, one becomes aware of many strange things going on in it, and one of the most phenomenal in our own time is undoubtedly what you may have heard described as the Brann system.” I should feel obliged to apologise for the word, and to call it ‘‘social dysidrosis,” were it not that the unamended name has passed muster as polite in that mirror of all that is polished and delicate, the Upper House. The system itself is a dreadful social malady, and, as you will readily understand, its symptoms are painful and distressing. It has been found to affect almost every class of the community; and Lord Dunraven is preparing a forensic mixture of anti-sudorific principles which we all hope will remove the cause of the disease. Now, gentlemen, it appears to me that in some respects we ourselves are needing the friendly aid of Lord Dunraven. If the system of tuition and examination in our profession were laid absolutely bare, his lordship’s eagle eye might mark some evidences of the destroyer in our very midst. It is needless for me to tell students of medicine what these evidences are, but, as some others are here present, I shall do well to mention one at least. Perhaps the most harrowing account of the sweating system was that which described a long string of pallidand haggard workers approaching the task master at a week’s end, each bearing on the head the burden so painfully accomplished. I have myself seen a similar string of pallid and haggard workers, two hundred in num- ber, approach in like manner the examination room. The pallor was identical, the careworn look identical; I thought I even noticed the same faint suggestion of the midnight oil. These, too, were each bowed down with a toilsome burden—not on, but in, their heads; and from their expression one could judge how heavy and wearisome these

ntleman need feel present

1008 THe Lancet,]

DR. C. H. RALFE ON FUNCTIONAL ALBUMINURIA.

(Nov. 24, 1888.

burdens were. ‘They were dead loads, in which the bearers had no living interest ; they were finished tasks that had given little satisfaction even when accomplished. I do not wish in the least to accuse the examination boards of such atrocities as ‘‘ sweating,” or even of ‘ drilling” — the latter a fatiguing process of delay described by Mr. Walter Besant. But may we not ask with some reason—and it is a question that has often been asked me by relatives and friends of the victims—whether it is good that a pro- fession in which a man requires the full measure of physical strength should be entered by a portal that in many cases casts a shadow with so ghastly a resemblance to the shadow of death? The fault ja not lie with the boards or with the students. The error creeps in somehow somewhere between, and it persists because the road between the two camps is not more freely traversed in both directions. If students knew what examiners really are, they would not make them the objects of a sort of fetish worship which ordains the sacrifice of a variety of unheard-of things at the sacred shrine. If the examiners knew what the students really do to appease their supposed malignity, their kind- ness and gentleness of disposition would cause them to take strenuous steps to emancipate the students from these burdensome works of supererogation. So that it is not so much a radical change of system that is required, however desirable some slight alterations may be, as that a fuller understanding should be come to as to what the present —_— really is. And, as in some measure furthering this object, I shall conclude what I have to say on the study of surgery by assuring you, gentlemen, that in acquiring that sound and practical knowledge of surgery which is of intrinsic value you are most wisely preparing not only for its actual employment in future practice, but for an easy passage through the portal that leads thereto.

THE PRACTICE OF SURGERY.

This is divided naturally into the two branches of private practice and hospital practice. With the latter you have to deal practically in your clinical studies now; with the former not just yet; so that I shall speak of hospital practice alone in the meantime, and attempt to indicate to you in what ways it is related to the studies we shall carry on here—how it is, in fact, in large measure their consummation, the realisa- tion of theory, and I hope its justification, by actual and patent facts. Till now we have spoken of study simply ; we must now revert to the same subject, but with added elements for our consideration. For the practice of surgery is still the study of surgery, and that in its most important and most interesting form—viz., the experi- mental. But it is something more. The facts are of the same kind, but far more interesting than those studied in the lecture room; for Nature is a much more eloquent and vivid demonstrator than any human teacher. To become her earnest disciple and to follow minutely every evidence of her meaning is the direct road to wisdom; and it is a road that, once followed, never becomes uninteresting or wearisome, though it may be long in leading to full en- lightenment. Yet that is not all; for in the practice of surgery you are dealing with scientific facts in a new relation. They are none the less interesting as scientific facts, but they are tinged for you with a new meaning—a new mystery it may be,—since they are at the same time a part of the burden of pain or anxiety that life has brought to your fellow mortal. In hospital practice you have therefore to be something more than a student of medicine; you must be a student of human nature. There you will see it at its highest and its lowest levels of development. No less will you discover something of its reserves and of its points of approachableness, and you will do wisely to cultivate this knowledge, which will be a great if not an essential aid in carrying on present study, and of invaluable future service to you when you have to tread the wider fields of your own practice. I am here commending this study to you asa matter of utility ; I might more strongly recommend it for its great intrinsic interest ; but I know, none the less, that you will be drawn to it by a yet stronger force, that of sympathy and of the desire to give something of your abundant vitality and cheerfulness in a quarter where they may be sadly and conspicuously absent. Whether, then, as a matter of interest, of utility, or of sympathy, it is the first essential of clinical study to be thus en rapport with your patients. For the most part your studies will be carried on with the aid of a clinical teacher, whose kindly manner will guide you greatly in this matter, just as his

experienced method of examination or actual treatment will indicate to you what it is important to know and necessary to do. In the Autobiography of Sir Robert Christison, I find a e which appears to me to illustrate the ideal at which the clinical teacher should aim. The order of his solicitudes is, firstly, the patient and his benefit ; secondly, the students and their instruc- tion ; and, thirdly, himself. In describing the late Baron Dupuytren, the eminent French surgeon, Christison has given us the practical realisation of this ideal. He thus describes one of his operations: ‘‘ Nothing could surpass the humanity and kindliness of this reputedly rough and ill-natured-looking man. He did not take a in the operation without asking and obtaining the child’s consent. While he was making his incisions, he was also constantly engaged in patting and coaxing the little fellow, and with such success that he only whined occasionally, but never cried. At the same time, every step was. accompanied by some words of explanation to the students, for which pope he moved his head from. side to side that all might see what he was doing. Of the threefold duty of operating, soothing, and demonstrating, no part seemed to interfere at all with another. The whole operation was over in a very short time and the child was carried out in his nurse’s arms, all the while calling out ‘Adiev, monsieur!’ Dupuytren. smiling and replying, ‘Adieu, mon cher petit.’” Such, in his hands, was the formidable operation of lithotomy at a. time when anaesthesia was still unknown, and when the difficulties and embarrassments of operating were only to be overcome by the courage and tact of which he was the consummate master. And of these he has left this record— the fair counterpart of that fame as an originator and dis- coverer by which the surgery of to-day recognises one to whom it is eternally indebted.

Gentlemen, in speaking of the prance of surgery I have entered on a topic that is all but limitless, and I have already tres; too far on your kind indulgence ; but I must rest satisfied with having attempted to show you in what spirit this study may well be prosecuted. It is a. study that will make you not only wiser but better men, for those efforts which will give you skill and deftness in dealing with the delicate and all too sensitive tissues of your fellow men will carry with them a tact and delicacy of feeling that will secure you the respect of others, and make you able and y to perform a noble func- tion in the work of the world.

ON THE CLASSIFICATION OF THE VARIOUS FORMS OF FUNCTIONAL ALBUMINURIA.

By C. H. RALFE, M.D. CAnTAB., F.R.C.P. LOND., PHYSICIAN TO THE LONDON HOSPITAL, ETC.

(Concluded from p. 955.)

Paroxysmal albuminuria.—In this form we have also frequent exacerbations, but they are not periodic, or, to speak more correctly, do not recur with the same regularity. In this form there is usually more disturbance than in the preceding. An apparently healthy person suddenly ex- periences a feeling of malaise, often ushered in with a distinct rigor, and accompanied with more or less disturb- ance of the digestive organs, from an increase of flatulence to queasy sensations or actual nausea. His skin becomes sallow, the conjunctive being even sometimes decidedly yellow. The next sample of urine passed after the onset of these symptoms is usually of deep orange colour, of high specific gravity (1020 to 1028), containing bile pigment as well as uro-bilin; an excess of urea is always present, and the albumen is abundant.! In some severe cases, when the rigor has been very noticeable, there have been blood corpuscles in the urine. In four cases out of sixteen well-marked instances of this condition, I have found that at one time or other the patient had experienced an attack of hemoglobinuria. The paroxysms, as before stated, are not periodic, occurring

1 In some of the cases, when I have y examined the character the transuded albumen bumen.

I have as well as serum-

THE LANCET,]

DR. C. H. RALFE ON FUNCTIONAL ALBUMINORIA.

[Nov. 24, 1888. 1009

irregularly at different periods of the day, and generally attributable to exposure to cold or to fatigue or mental worry. In > one case have I noticed anything like periodicity, and in that the paroxysms occurred every after- noon, alittle later each day, till after a fortnight they ceased. In this case, however, the paroxysms were accompanied by a rise of temperature (101° to 102°), and followed by profuse sweating, and was evidently of malarial origin. This is the only case in which I have noticed a rise of temperature. The duration of the attack varies very considerably, the next succeeding sample being sometimes almost free from albumen; whilst in other instances it remains persistent and tolerably abundant for days and weeks together. In this class of case no fresh paroxysms may be remarked, but more usually there are from time to time slight fresh exacerbations, though never ames in severity the original seizure. ‘These are the characters of a well-marked instance, but the disorder may be present in a much less characteristic form, and, beyond a feeling of slight malaise, the patient may not be aware that anything is amiss. In some rare instances I have noticed the urine to be of a lower specific gravity than usual; but in these cases the urine was in- creased in quantity. With regard to the causation of

roxysmal albuminuria, in a paper read before the British

edical Association at Brighton, 1886, I expressed m belief that the albuminuria depended upon inevetiend hemolytic action of the liver, causing an over-destruction of blood corpuscles, and thereby an increase of urinary pigment, often of bile pigment as well, and an excess of urea; whilst the albumen which escapes conversion was got rid of by the kidneys. This view has received support from the experiments of Noel Paton and the clinical observations of Dr. Oliver of Newcastle, of which I was ignorant at the time I drew my own deductions. The hypothesis, moreover, helps to explain the occasional relationship between paroxysmal albuminuria and hemo- globinuria, for as I then pointed out, if increased haemolysis caused an increase of urea, bile,” urinary pigment, and albumen ; excessive hemolysis, may cause hemoglobinuria, the destruction being so t that the hemoglobin is not all converted into bile and urinary pigment and urea before at is reabsorbed and carried into the circulation. The functional albuminuria sometimes found associated with glycosuria is, I believe, also paroxysmal in its character, and is probably caused in the same manner, some disturb- ance of the metabolic process going on in the liver. In four eases I have had recently under my observation, I have noticed very distinct fluctuations, with marked exacerbations and remissions quite independent of the amount of sugar present, that are very characteristic. This peculiar associa- tion of functional albuminuria with glycosuria is worthy of more attention than has yet been paid to it. One point has particularly struck me with regard to it, and that is how slightly either the sugar or the albumen is affected by diet, which makes me suspect that both are derived from some other source than directly from the malassimilation of albuminous and saccharin ingesta. The transient albu- minuria occasionally met with, especially in middle-aged women, about the time of the menstrual period, also seems to me a paroxysmal form. Certainly, when observed, the patient is always decidedly sallow, if not actually yellow, and this, again, seems to associate it with the condition described by Senator as icterus menstrualis. Unlike the generality of cases met with in the cyclical form, the patients who suffer from paroxysmal albuminuria are usually about middle , the average of my cases being thirty-seven years; only one case was observed under twenty years, and none above fifty. As regards sex, seven- ‘eighths were males. Of cases of albuminuria associated with glycosuria, three were males, the youngest fifty-four oes and the eldest seventy-two years, and one female of

orty-five years of age.

Intermittent albuminuria is a term that should be used when we wish to speak of an albuminuria that is neither cyclical nor paroxysmal. It comprises a considerable number of cases that differ considerably from each other, both as regards the character of the intermittences and with respect to the causes that apparently induce them. It may be as well, then, provisionally to further subdivide this group according as the cases seem to depend upon (a) digestive, (6) neurotic, and (c) toxic agencies for the production of the

2 Dr. Oliver, of Harrogate, has found bile acids in the urine in some eases of functional albuminuria. :

albuminuria. (a) In this form the albumen is found in the urine shortly after the ingestion of food; in some cases it has been induced purposely by partaking largely of raw eggs ; in this case probably the foreign albumen thus taken in excess is partially eliminated by the renal epithelium. Cheese is said sometimes to cause albuminuria, but the instances do not seem to be well authenticated. The peculiar albumen (alkali) of milk I have recognised in the urine of patients taking it in large quantities, but in these eases the urine was previously albuminous. Apart from these instances, the albuminuria of digestion is probably due to too active metabolism in the liver, and an albumen unfit for assimilation passes too hurriedly into the circula- tion and is thrown out by the kidneys. This form of albuminuria is most commonly met with at the extremes of life—in children and elderly people. Among the latter I have often found it associated with gout. (6) Albu- minuria the result of disturbed innervation is frequently met with. A shock or fright may cause the urine to become albuminous for hours after. More commonly the albuminuria arises from reflex disturbances. Irritation of a nerve plexus on the peritoneum has experimentally been found to cause albuminuria. Dr. Matthews Duncan has stated that ———— a tempo albuminuria is not infrequent. any cases probably of the intermittent albu- minuria of young persons are due to reflex causes, especially of the generative organs, since jt is at the age of puberty that the albuminuria of adolescents is generally first observed. Albuminuria in a child with an elongated prepuce was cured by circumcision. But the most direct influence of the nervous system in the production of albuminuria is shown by the evil effects of over-study combined with anxiety, which is fostered by the present competitive system. Andrew Clark, in some comments he made at Dublin, when speaking on Professor nr =p Stewart's paper on Albu- minuria in the Apparently Healthy at the Association meeting last year, remarked upon the frequency of the rejection of candidates at the medical examination for the Indian Civil Service owing to peed omyer of albumen in the urine. The same observation will be confirmed by the ——— of our medical schools. Hardly a session passes ut I am consulted by some student who has discovered albumen in his urine whilst reading for his examination, and of whom I hear no further when his troubles are over. Life insurance examinations sometimes induce the con- dition. I remember some few years ago rejecting a candi- date whose urine was loaded with albumen at the time of the examination. The same night I received a letter from the proposer’s brother, who was a medical man, saying he was sure I was mistaken, as he had examined his brother’s urine after his return from the life office, and found it perfectly free from albumen. He also wrote to the secretary, request- ing that his brother should be examined for the office by another physician. This was agreed to, and I felt rather anxious lest the albuminuria should not recur on the da; appointed. But the second examination never came 0 On the morning of the day fixed for it we received a tele- gram saying that the brother had that morning found the urine albuminous—for the first time for fourteen days since its detection by me. (c) The albuminuria caused toxic agents has not been sufficiently studied to speak of it with much positiveness. A dock labourer, who had become ‘‘dead drunk,” was found to have the urine in his bladder albuminous ; this rapidly passedoff. Dr. MeGregor Robertson has induced albuminuria experimentally by injecting atro- pine. Constipation of the bowels may be considered one of the causes of this form of intermittent albuminuria. Dr. Mahomed, however, considered that constipation induced albuminuria by raising the pressure in the renal vessels; but I am inclined to the view that it is caused by the toxic action of the reabsorbed faecal products, the urines of such patients often containing an excess of indican and oxalate of lime. At all events, it is an albuminuria usually easily remedied. A medical man in the West of England, who con- sulted me with reference to the presence of albumen in his urine some three or four years since, writes to me to say he is ‘in excellent health, hunts twice a week, and never sees albumen unless he has forgot to take his Friedrichshall water for some days.” Albuminuria the result of muscular exercise is a subject of dispute, some writers insisting upon its frequency, others maintaining that it is com- paratively rare. us, one author puts it at 16 per cent., another at as low as 3 per cent. I incline to the lower

quotation, as I believe that the effects of m

1010 THe

MR. C. WILLIAMS ON STONE IN THE BLADDER.

[Nov. 24, 1888.

exercise in the production of albuminuria have been much exaggerated. Intermittent albuminuria differs, as already stated, in not exhibiting a cyclical or paroxysmal tendency, but occurs sometimes continuously for days, and then inter- mits, whilst in other cases the intermission is diurnal. The absence of any periodicity or paroxysmal tendency thus distinguishes cyclical and paroxysmal albuminuria from simple intermittent albuminuria; but it is more important to distinguish the latter from the intermittent discharge of albumen, which is frequently observed in chronic inter- stitial nephritis at that period of the disease when it is passing from the pre-albuminurie stage into that in which the albumen becomes persistent in the urine. Our difficul- ties are, moreover, increased in this case by the fact that, as the renal epithelium and tubules are but yet little affected at this period of the disease, we do not find casts or desquamated epithelium to help us to form a diagnosis. The only clue afforded likely to be of assistance is to be found in the polyuria and high tension of the pulse, and even these are sometimes not sufficiently well marked to

ive confidence to an immediate opinion. I need hardly say it is of the utmost consequence for the medical attendant to be aware of this difficulty, and to withhold a too early ex- pression of opinion. He should constantly examine the urine at different periods of the day, and under varying conditions, with regard to food, exercise, regulation of the bowels, and especially compare the amount of urine passed with the quantity of fluid ingested. This latter is a very important point, for I have found that the polyuria of chronic intersti- tial nevhritis does not depend proportionately on variations in the amount of fluid ingested, but on the degree of arterial tension; whilst in functional albuminuria the correspondence between the fluid ingested and that passed out of the body follows the ordinary physiological law. The scope of the present paper, however, does not admit ot my dealing with the very important subject of the diagnosis between the various forms of functional and organic albuminuria, and I can only insist here upon the utmost care being taken before an opinion is definitely arrived at, more especially as the form of organic albumi- nuria, which is most likely to be regarded as functional, is that in which the disease has not yet gravely involved the epithelial structure, and in which appropriate treatment can be most advantageously employed. A mistaken view of the case at this period is therefore most disastrous, as time is lost whilst the renal degeneration is advancing. I hope on some future occasion to enter more fully on this subject, and also to deal at length with the questions of prognosis, etiology, pathology, and treatment so far as they affect functional albuminuria.

Queen Anne-street, W.

STONE IN THE BLADDER IN CONNEXION WITH ENLARGEMENT OF THE SPLEEN.! By CHARLES WILLIAMS, F.R.C.S.,

SURGEON TO THE NORFOLK AND NORWICH HOSPITAL.

THomMAS P——, aged thirty-two, a farm labourer, was admitted into the Norfolk and Norwich Hospital under my care on March 24th, 1888, suffering from a stone in the bladder. He was a short, thick-set man, with a profusion of black hair, and was fairly well nourished. When he pre- sented himself for admission, it was noticed that his con- junctive and eyelids were suffused with blood, caused, as he said, by the efforts he was compelled to make in straining to pass his urine. He had been an inmate in the above institution two years previously under my colleague, Sir Peter Eade. He was at that time the subject of inflammatory dropsy, and had a semi-myxcedematous condition of the tissues. The urine contained a large amount of albumen. The face, hands, and abdomen were edematous. The spleen was found to be much enlarged and very hard; the liver was also enlarged. The account he gave of this condition was that two months prior to this attack he had suffered from acute bronchitis, and that the dropsical symptoms had appeared about a week previous to his admission. He remained under treatment in the hospital several weeks,

1 Read before

the Congress of Physicians and Surgeons, Washington,

U.S.A., September, 1

and when he left his health had greatly improved. The general swelling had disappeared, but the spleen still remained large and hard, and the liver slightly so.

On readmission in March of this year, he informed me that the symptoms of stone showed themselves about a year previously. They began by a frequency of micturition, which became more urgent as time went on; this was succeeded by an inability to retain the smallest quantity of urine, which was, indeed, constantly dribbling away, and he noticed how severely it scalded him. He had sand and gravel in the urine for six or seven months ; occasionally there was blood in it. About one month before admission hemorrhage took place into the con- junctive and eyelids of both eyes, caused no doubt, as he said, by straining in conjunction with the efforts made by the bladder to expel the stone rather than to expel any urine, which was evidently not permitted to accumulate. He had always been a most temperate man, taking occasionally mild beer, but no spirits. He had never suffered from ague, or syphilis, or fever of any kind.. He had a good deal of colour in his cheeks and lips. One could haste imagine him to be very ill; he certainly had not the appearance of being so, although his skin gene- rally was Py yellowish colour, and looked like wax. The sight was good; appetite bad; tongue pale and lightly furred. The heart sounds were feeble, but normal; the lungs resonant on percussion; but the breath sounds coarse at the right base. The spleen was greatly enlarged ; it extended inwards an inch to the right of a line drawn from the ensiform cartilage to the umbilicus, and down- wards two inches below the level of it; its surface was smooth and poten hard. The liver was plainly felt a little below its normal line. The urine was intensely acid ; it contained a small quantity of albumen, and the specific gravity was 1015. (Edema of the legs and feet. usually made its appearance towardsevening. Onsounding, the bladder, a hard calculus of large size was readily detected. An attempt was made to measure it; this could not be accomplished, inasmuch as the bladder was felt to be firmly grasping the stone, and, as this viscus had not. retained any quantity of urine for several months, it was. not consitarel prudent to dilate suddenly with water an organ that had been so long in a contracted condition. The

neral aspect of the patient, and the uliar symptoms.

e was labouring under, made it evident enough that.

he was not only affected by this irritant in his vesicab organ, but that he was the subject of splenic leukemia. Examination of his blood showed that the leucocytes were greatly in excess of the red corpuscles. This unfor- tunate state of his system precluded the idea of an operation for the relief of the stone until the general con- dition of his health should be in a more improved state, and for the next seven weeks he underwent several kinds. of medical treatment, but without any beneficial result. He now became impatient and clamorous to be relieved of the caleulus, which was causing a large amount of distress and discomfort. In the end gp reluctantly to his. wish; I still considered him to be in every respect a most unfavourable subject on which to perform any operation, but that under the circumstances aynaps am ¢ would be perhaps the best and safest rs to adopt. This was. accordingly performed on May llth, after he had beem laced fully under the influence of ether. The stone was. nard and tough; the débris, when dry, weighed 256 grains,, and was re me almost wholly of uric acid. The next. day he complained of much pain over the region of the bladder and along the urethra. He a deal of blood as well as several pieces of stone, and he perspired freely for several days. On the fifth day the patient was well enough to undergo completion of the operation, agaim under the influence of ether, which he inhaled badly, and recovered from with difficulty. The débris weighed 436 grains, and with the former amounted to 691 grains. Shortly afterwards he had a severe rigor, which lasted several hours. Three days later he complained of a violent pain in the hypogastric region; a colliquative diarrhea set in, consist- ing of thin yellow motions. His temperature was 102°; pulse 120; tongue dry; no sickness; features pinched; and great prostration ensued. These symptoms e daily more marked, and were not alleviated by any form of treat- ment; to them he succumbed on the eighth day, the diarrheea persisting to the end.

An examination of the abdomen was made after death.

A good deal of pus was seen over the er, which was

THE LANCET,)

MR. C. WILLIAMS ON STONE IN THE BLADDER.

[Nov. 24, 1888. 1011

matted posteriorly to the pelvic fascia. The bladder was contracted to a size just | enough to contain the stone ; its walls were extremely thick; several small fragments of stone and some turbid urine were found in it. The mucous membrane was congested, and presented a few white patches; the rugs were very prominent; the prostate not enlarged. The kidneys together weighed 14 0z.; they were le. On section the cortex seemed to be somewhat iminished; the papillae were enlarged and well marked; the pelvis of the right one was dilated. On the whole they looked remarkably well and healthy. The liver weighed 6 lb., and was firm on section. The spleen weighed 4} Ib., and had contracted firm fibrous adhesions to the diaphragm. The surface was mottled, and on making a section its structure was seen to be dense and firm. The application of tincture of iodine gave a well-marked reddish-brown reaction; it presented, indeed, a good example of amyloid degeneration.

y reason for bringing this case before the notice of the profession is that it presents several features of considerable mterest, and especially one which I may venture to say is, so far as I can learn, new to surgery.

The number of diseases the patient had in a short space ef time is singular. He first of all suffered from an attack of acute bronchitis; after his recovery from this, acute albuminuria supervened, from which he ap’ to have recovered, or nearly so. He was then found to have en- largement of the spleen. This was followed by a con- dition of leukemia and the formation of a stone in the bladder.

It was a difficult matter to ascertain for how long a time he had been the subject of splenic disease. e was known to have had the enlargement certainly for two years, inasmuch as this condition was noticed when the man was in hospital in 1886, but for how long a

riod before that is uncertain. The connexion, therefore,

. In point of time, between the commencement of the enlarge- ment and the formation of the calculus cannot be accurately made out. When under treatment in 1886, he made no eomplaint whatever of bladder trouble; in all eye he had no stone in his bladder at that time, or else a very small one. Anyhow, the calculus was of not more, or very much more, than two years’ growth, during which time it attained the weight of not less than twelve drachms, and it consisted almost entirely of uric acid with a small amount ef urate of ammonia. I need not say that this is an un- usually rapid formation of a vesical calculus, but it is to be —— by a singular fact—namely, that in cases of enlarged spleen, especially in those who suffer from anzmia, a large amount of uric acid is usually found in the urine. On this point, Senator, in Ziemssen’s Encyclopedia of Medi- cine, vol. xvi., observes: ‘‘There is much reason to believe that the spleen is, if not the only, yet a very important source of uric acid, and when the spleen is enlarged uric acid is produced in larger quantity than usual; we see this in splenic anemia.” Ranke found that in such cases uric acid was increased by one-half—from 0°648 to 0°915 part in 1000; Pettenkofer and Voit found the average of five normal men to be 0°872, while that of a leucocythemic patient was 1°424, an increase of 64 percent. Ossikoosky also found an increase, the excretion being on an average about twenty-two grains in the twenty-four hours. A similar increase was noticed 7. and by Berrell. In the case of the latter, a boy aged seventeen excreted 18°28 grains daily—1‘50 parts in 1000,—the average for a boy of the same size and weight, on scanty diet, being, according to Parkes, only six grains. Bartels found an enormous increase in one case, the daily excretion being 42 grammes, or about sixty grains. The formation of so large a stone consisting of uric acid in so short a space of time in my patient may thus be reasonably accounted for, the usual rate of growth in ordinary cases being about two drachms in the year. In Bartels’ case, if only one grain of uric acid daily out of the sixty had gone towards the formation of a calculus, two years would have sufficed to produce one twelve drachms in weight.

e next point presents a circumstance of great interest and significance, especially to the operating surgeon. In splenic leukemia the blood is found to be deprived to a great extent of its red corpuscles, and the number of leucocytes is very much increased ; in such cases there is a tendency to

on which to perform any kind of operation, major or minor. The low vitality of the blood and a tendency to disintegra- tion of tissue scarcely render recovery possible. No operation therefore, unless of urgent necessity, ought to be attempted. Even the operation adopted in my patient does not seem to be a particularly safe one. This singular fact, that leukemic subjects usually succumb to fatal hemorrhage after operations, has not been recognised by the profession, certainly not by authorson practical surgery. Alargenumber of surgical works and periodicals have been searched, and no information bear- ing on the particular question could be found. The only allusion to the subject occurs in a paper by Sir Josep Fayrer in the Medical Times for 1874, in which he refers to the anemic inhabitants of malarious climates, and observes that ‘‘in such cases the slightest wounds have been followed either by gangrene or by hemorrhage.” Again, he says, ‘Surgical operations, excepting such as are imme- diately necessary to save life, should be avoided in this state, the tendency to hemorrhage, gangrene, or embolism being very great.” These remarks are exceedingly valuable, although they apply more especially to the natives of India. The unfortunate result of my patient fully bears out the truth of Sir Joseph Fayrer’s remarks. There was, indeed, a great disposition to hemorrhage, as shown by the effusion of blood into the conjunctive and eyelids, as well as from the bladder. It was only as a matter of urgent necessity be! su attempt was made to relieve him, and it ended fatally.

With the hope of obtaining further information on this deeply interesting subject I appealed to my professional brethren in the pages of THE LANCET in May of this year. The only response was on the part of my colleague, Mr. Cadge, who kindly forwarded notes of two very instructive cases that had fallen under his observation. Mr. Cadge says: ‘In 1861 I assisted a medical friend with a troublesome case of stone. The man, aged fifty-four, was corpulent and asthmatic. Three years previous y an ineffectual attempt had been made to do lithotrity. The stone was broken, but not removed. The man continued to suffer, and had con- stant and great bladder irritation and cystitis. Two large stones were removed. The operation was tedious from repeated slippings of the forceps. There was free but not serious hemorrhage. No plug was used. The patient died two days after the operation. The prostate was freely divided. The bladder was contracted ; the mucous membrane thickened and congested; the muscular coat thickened. The ureters, pelves, and tubes of the kidneys were much dilated. The spleen was of an enormous size—nearly as large as the liver.

he next case, which occurred in 1866, was that of a gentle- man aged sixty-four, a florid, almost purple-faced gouty man. The stone was removed by median lithotomy; the operation was easy and quick, and no bleeding occurred at the time. In a few hours hemorrhage came on, apparently from the

rostatic veins; it did not escape externally, but filled the bladder, and clots were frequently extruded. It ceased in twenty hours; the urine then became clear, and he seemed in every way doing well for four days. On the fifth day he ate an indigestible meal; this was followed by oppression, and in a few hours by a ee and perspiration ; rigors followed every day or two. He became delirous, and died a fortnight after the operation. At the post-mortem exami- nation the bladder was seen to be healthy ; the mucous mem- brane pale; the parts about the prostate rather congested. No pus was found anywhere. The kidneys weye | and congested. There were two or three small stones in one, and some pyelitis. The liver was large and very congested ; the spleen four or five times its normal size, tinged with blood, soft, and easily lacerable.” Mr. Cadge remarks: ‘I have always felt uncertain as to the exact cause of death in this case. The symptoms were those of py«mia, but the pathology was certainly not consistent with that view. ”

Tnese two cases go far to establish the fact that those persons who may happen to be subjects simply of enlarge- ment of the spleen are as liable to serious risks, should any operation be performed on them, as are those who suffer from splenic leukemia, in which condition the tendency to hemorrhage is so tas to render an operation of any kind

searcely justifiable. In corroboration of this view, Sir Joseph Fayrer, in a private communication to me, says: ‘“‘ In cases of splenic enlargement I would avoid all operations not absolutely necessary to save life and relieve suffering, even although there be no leu anemia.

cocythemia or apparent

rrhage, and the uence is that those unfortunate persons who are afflicted with this affection are bad subjects

Norwich

1012. THe Laxcer,]

DR. T. OLIVER: ADONIDINE IN HEART DISEASE.

(Nov. 24, 1888,

ADONIDINE IN THE TREATMENT OF HEART DISEASE.

By THOMAS OLIVER, M.D., M.R.C.P. LOND., PHYSICIAN TO THE ROYAL INFIRMARY, AND LECTURER ON PHYSIOLOGY, UNIVERSITY OF DURHAM COLLEGE OF MEDICINE, NEWCASTLE-UPON-TYNE.

In the recent additions that have been made to our medicinal armamentarium the heart with its diseases has not been overlooked. An ever-widening physiology and an appreciation of the results obtained by experimentation have increased, amongst other things, our knowledge of the action of drugs, and particularly is this the case as regards those employed in the treatment of diseases of the heart and circulation. Each new drug introduced to the profession and recommended for heart disease has to run the gauntlet of physiological no less than of clinical criticism, and must fulfil certain requirements to be considered worthy of our employment, or for its name to be retained on our list of valuable therapeutical agents. There are many things

uired of a heart tonic. It must so act upon the heart as to improve the contractions of that organ, and in this way relieve any precordial pain or sense of difficulty of breathing that may be present; it must raise arterial tension if this is too low, and in this way promote the removal of water from the system through the kidneys. And there are two methods by which this arterial tension may be raised. One method is by the drug acting upon the heart itself; its muscular wall, contracting with greater power, sends out blood in larger quantity and with greater force; emptying itself thus more perfectly, the coronary arteries are flushed with larger quantities of blood ; the nutrition of the heart is thus better secured, and the nutrition of the tissues is maintained. The other method is for the drug to raise arterial tension indirectly— so acting, in short, upon the peripheral arteries that they contract, and in this way not only is the blood retained within them, but it tends to be thrown back upon the heart, and we rely upon that organ having still a sufficient amount of energy latent in its walls to respond favourably to the somewhat increased pressure within its ventricles. An effective circulation means functional activity of heart, arteries, and veins. We cannot overlook the claims of the arteries in any therapeutical consideration, for it is they that carry on the work when the heart is in a state of diastole.

The chief danger in heart disease arises from reduced arterial tension, for the heart itself, no less than the systemic capillaries, then suffers in consequence. If, therefore, this is a danger, our duty is clearly to maintain the blood pressure; but to dothis effectively we must improve as far as we can the movements of the heart as the emitting organ, the arteries as the carriers, and certain nerve centres as regulating the distribution of the blood. When I am called to treat a case of heart disease, and I have made out to my own satisfac- tion the nature of the cardiac lesion, then it becomes with me less a question of murmur than what is the condition of the wall of the left ventricle. Is there compensation ? and, if so, is it sufficient or has it given way? Is arterial tension low? and, if sv, can it be raised? Now for all practical purposes digitalis answers very well. Digitalis, although an old drug, is difficult to replace, and this simply because its therapeutics are modern and are now better understood. ‘True, it fails every now and then, and satis- factory results can be obtained by strophanthus or conval- aria. It is in mitral regurgitation that the action of -igitalis is seen to advantage, although in many cases of aortic regurgitation digitalis in my hands has answered remarkably well. Once the actual condition of the left side of the heart is appreciated, and with it that of the right ventricle, the careful administration of any cardiac tonic will seldom be disappointing. For the last few months, however, I have been watching the effects of drugs in cases of heart disease viewed in the light of their causation, and from what I have seen of adonidine I have come to regard it as a drug capable of giving great relief to many of the unpleasant symptoms of heart disease.

donidine is a glucoside of Adonis vernalis, and was written up, if I may use the term, by Da Costa, who used it as a pure cardiac tonic. Under its administration

he noticed a rise of temperature where it had previously been subnormal, and an ‘increase in the strength and action of the heart. It had no diuretic action, however. He thinks it will never supersede digitalis, and that it answers best in cases of dilated heart. The cases in which I have tried it have been chiefly those of aortic and mitral regurgitation. In all of them great relief was given to precordial pain, to the pain which ran down the left arm, and to palpitation and dyspnea. I give it, combined with such things as sal volatile or chloroform water, in doses of one-sixth of a grain four times a day. It is a powerful drug, and is not borne well, particularly at first, in doses larger than this. Frequently, in fact, [ begin with one- eighth of a grain, and I find this quite enough. Here is an epitome of some of my cases :—

J. G , aged thirty-four. Rheumatism twelve years. ago. Has aortic and mitral aa itation. Urine not. albuminous; it averaged 244 0z. ore treatment, after treatment 270z., daily. Pulse 76. Made a satisfactory recovery.

John T . forty-five. No rheumatic history. Is a. labourer. Much exposed to wet and cold. se 70, water-hammer. Aortic and mitral regurgitation. Urine: not albuminous ; it amounted to 340z. before treatment, and 36 oz. after it.

Joseph L——, aged thirty-one : watchmaker. Rheumatic history. Pulse markedly water-hammer. Extensive aortic and mitral regurgitation. Adonidine in doses of one-sixth of a grain, thrice daily, relieved all his unpleasant sym- ptoms, such as throbbing in the head and neck, noises in the ear, precordial and brachial pain, and profuse perspira- tions, and he could walk better, without having such severe attacks of palpitation; but severe headache cameon when he was taking the drug, which was quite unusual to him. The medicine was discontinued for two days, when his headache disappeared, but under its use, in doses of one-tenthof a grain, he again remained for months remarkably well. Digitalis,

, but nothing gave relief until he took adonidine.

uke B——, aged fifty-six; mariner. No rheumatic: history. Urine not albuminous. Aortic and mitral regurgi- tation. Before treatment his urine averaged 23} oz. daily, and 364 0z. after it.

W. H. H——, aged forty-four; sailor. No rheumatic: history. Pulse 64. Aortic and mitral regurgitation. Before treatment his urine amounted to 3040z. daily, and 384 oz. after it.

John B—, aged forty-six; a miner. No rheumatic history. Aortic and mitral regurgitation. Urine not. albuminous; before treatment it averaged 32 0z. daily, and 404 oz. after it.

Luke F-——, aged thirty-four; a sailor. No rheumatic history. Aortic and mitral regurgitation. Pulse 88. Urine- not albuminous ; before treatment it averaged 494 oz. daily, and 40# oz. after it.

Adonidine has, in every case that I have given it, relieved all unpleasant symptoms. Every patient who has taken it has expressed himself, after a few days” trial of it, as feeling very much better, and that not in one direction only. The painful throbbing of blood- vessels, headache, and profuse have, im addition to dyspneea and preecordi

Pk ig rp belladonna, and also cyanide of zine had been tri L

ial pain, disappeared ;. and whilst in most of the cases there has been a slight. increase in the amount of urine thrown out after treat- ment, I am inclined to think that adonidine has little diuretic action. It is acardiac tonic. It acts chiefly upon the heart, gently raising arterial tension; it has something of the sedative action upon the heart that belladonna has.. It relieves the sense of increased intra-cardiac pressure; and the cases of aortic regurgitation in which, I think, it answers best are those where the lesion is due either to- traumatic rupture of the valve or to chronic aortitis, and. where it has not arisen from rheumatic endocarditis. Newcastle-upon-Tyne.

RAILWAY SERVANTS AND AMBULANCE WORK,. BIRKENHEAD.—The Mayor, Mr. F. Thornely, the chairman of the Birkenhead centre, distributed, on the &th inst., the certificates of the St. John Ambulance Association gained by the class of the staff of the joint lines at Woodside station. The class is composed of twenty-six members, all of whom had passed the examination. Dr. Cornwall of Hamilton-square was the instructor. In the Birkenhead centre there are now sixteen large am classes.

Tue LANcET,) DR. T. D. SAVILL: TETANUS TREATED BY CHLORAL HYDRATE. [Nov. 24, 1888. 1013

CASE OF TETANUS TREATED BY CHLORAL HYDRATE; RECOVERY.

SECTION OF MEDIAN NERVE FOLLOWED BY TROPHIC LESIONS OF MUSCLE AND SKIN,

By THOMAS D. SAVILL, M.D., M.R.C.P.Lonp., MEDICAL SUPERINTENDENT OF THE PADDINGTON INFIRMARY.

D. F——, aged twenty, a bargeman by occupation, was admitted into the Paddington Infirmary on Sept. 20th, 1887. Hecould tell us nothing about his family antecedents, though he thought that his mother had died of consumption. Nine years previously he had suffered from abscess of the neck for about two years, and these had left the present puckered cicatrices. Beyond this there was nothing to note in his previous history, and he had led a very abstemious life. Two weeks before admission he tripped and fell on to a heap of rubbish, and cut his wrist with a broken piece of china. It bled a little, but did not cause him much concern. However, it seems to have been a bad cut, and it did not unite by first intention, for it left a white scar just external to the middle of the anterior surface of the right wrist joint. He was a good deal exposed to cold and wet after this; and four days before admission gave up work on account of feeling ill and ‘‘a difficulty in chewing and swallowing anything,” as well as a stiffness of the muscles of his neck.

On admission he still complained of these symptoms. There was, moreover, some obvious rigidity of the muscles about the neck, and we could not examine his throat on account of his inability to open his mouth. The thoracic and abdominal viscera were natural. The temperature was normal, and it may be noted at once that it only once reached 100°. The rigidity of the muscles of the neck soon spread to those of the back and the other parts of the body. It consisted of a tonic spasm, liable to severe and painful exacerbations. During these attacks of intermittent spasm, which became more and more frequent, he would arch his back, hold his breath, and then groan with the agony. The skin would become bathed in prefuse perspiration and the face assume that rigid grin known as the risus sardonicus. He had from four to seventeen of these attacks in twenty- four hours during the first six days he was under treatment. But the spasm, especially that of the muscles of the neck and jaw, never completely relaxed, and it was with difficulty that fluid nourishment could be poured into his mouth and swallowed. All the muscles of the body were affected, but those of the arms less so than other parts. He suffered from retention of urine on the day of admission and for some time afterwards, probably from spasm of the sphincter of the bladder, for there was no other obstruction. And it is curious to note that the bladder itself seemed to be affected, for after passing a catheter the urine did not flow in a uniform stream, but in a wavy, intermittent manner. He was treated from the commencement with chloral hydrate (twenty grains every four hours), occasionally combined with bromide of potash; and a further dose of forty grains of the first-named drug at bedtime if necessary.

And now I come to the chief point of interest in the case—the relief by chloral hydrate. We have seen that he was taking 100 and 160 — of this drug in the twenty- four hours, and it seemed to be doing him good, for we noted that the spasms were markedly diminishing in severity and frequency. But these large quantities had produced a most troublesome complication—that of vomiting; and so on the twelfth day of the disease (seventh day of treatment) the chloral hydrate was —— That same evening the spasms returned with tenfold strength, and if it had not been for the yf prompt administration of chloroform the patient would have died of asphyxia. It was on one of these occasions (Sept. 28th) that the medium nerve was divided. Next day (thirteenth of the disease) the chloral was resumed, but this time partly by rectum and partly, com- bined with bismuth, by mouth. The sickness returned to some extent, but the severity and frequency of the spasmodic attacks gradually diminished. On the seventeenth day of the disease the patient took the law into his own hands, and positively refused all day to have his medicine. The same evening he was again seized with most violent

1 Paper read at the Medical Society of London, Oct. 29th, 1888.

spasms and impending asphyxia, which was only averted by the prompt administration of chloroform. On resuming the chloral hydrate, partly by mouth and partly by rectum, the spasms became gradually less severe. The gastric derangement continued to be troublesome, and on the twentieth and twenty-first days of the disease he had some Pg attacks, probably also due to the drug; but from this time he gradually recovered. The spasms ceased after Oct. 11th (twenty-five days from the commencement of the affection), and he got up about the end of October.

Bearing in mind the history of a wound two weeks before admission, and the scar on the front of the right half of the wrist, which, however, showed no signs of irritation at the time of his being seen, it was thought advisable to divide the median nerve in the arm. This was done, and half an inch of the nerve trunk was removed under antiseptic pre- cautions on Sept. 28th (twelfth day of the disease and eight days after admission). The two ends were loosely connected by a piece of catgut. A small piece of catgut was placed in the lower angle of the wound, and the skin brought together. The catgut drainage was removed on the second day, and the wound had healed by first inten- tion. There is nothing surprising in this operation being followed by weakness of the muscles and anvsthesia of the skin supplied by the median nerve. This, it was hoped, would pass off after the nerve had reunited. But it was not so; the weakness of the muscles increased ; they became atrophied, presented a marked reaction of degeneration, and at the end of three months I was surprised to find a blister had formed on the knuckle of the index and second finger without obvious cause. This blister soon became open sores, which have never healed for any great length of time during the past nine months. About this time also we noticed that the skin over the right half of the palm of the hand was rougher and redder than that over the left; and that this half of the hand perspired a great deal more than the other, pointing to a vaso-motor lesion. These conditions have also persisted up to the present time. He was treated by galvanism, massage, and faradism without result. Eight months after the original section it was apparent that the continuity of the median had been re- stored, to some extent at least, for the affected muscles still retained some power in them, and direct pressure on the nerve trunk ate the seat of operation produced pain. Dr. de Watteville kindly saw the case about this time (June, 1888) for me, and, as he concurred in the opinion that the median was the seat of some irritation, it was decided to cut down and explore the nerve at the seat of the original operation. This was done on June 8th, and a fusiform enlargement on the course of the nerve, an inch long, was removed, and the cut ends brought close together. His arm was put up in a perfectly fixed position for ten weeks, and since this he has used the hand moderately. At the present time, thirteen months after the operation, he still has sores on the knuckles, and the condition of his arm is very much as it was five months ago. The muscles are atrophied, the right middle finger is one-eighth of an inch shorter, and this and the index fingers are narrower and more pointed than the left. However, he undoubtedly has more use in the hand than he had.

Remarks.—This is a typical case of tetanus, except from the fact that the patient recovered. The percentage of mortality is very high. According to Mr. Poland, quoted by Dr. Bristowe,? 88 per cent. of the cases end fatally. It might be said that the favourable results in the present case is attributable to three means. Firstly, chloroform, Un- doubtedly this agent averted death on two occasions, but if was not employed with sufficient continuity to make us attribute the whole of the result to its use. Secondly, division of the median nerve. It is not likely that this pro- duced any beneficial effect, for the most dangerous spasms, those on the night of the seventeenth day of the disease, occurred subsequently to the division of the nerve. Thirdly, chloral hydrate. When we attribute a controlling influence to any drug which has been continuously administered during the course of a disease, we are always confronted with this fallacy: that, after all, the disease might have taken that turn without the drug being administered. But in the case of the man F——, on two occasions when the dru was stopped the symptoms took on an alarming severity, an when the drug was resumed there was a very mark amelioration. In a valuable paper by Mr. Wallace,® based

2 Theory and Practice of Medicine, fourth edition, page 1091. 3 THE LANCET, vol. ii. 18 2, p. 21%.

1014 THe LANCET,]

MR. CUMBERBATCH AND DR. STEAVENSON ON DEAFNESS.

(Nov. 24, 1888.

on his experience at the Calcutta College Hospital, it is stated: “If any drugs are to be relied on, favour is decidedly on the side of chloral, opium in the form of morphia, and opium smoking.” My case tends to show that the chloral hydrate should be given in large doses and continuously.

e unusual condition of the skin and vaso-motor lesion have been alluded to. It would seem probable that they depend upon the irritative nature of the changes in the nerve trunk. As to the prognosis for complete recovery from his arm troubles, I was inclined at one time to take a very gloomy view, and thought of suggesting a transplantation of nerve from an animal, as in Gersung’s case. But since reading in Hilton’s ‘‘ Rest and Pain” of two or three cases of injury to nerve which completely recovered after several years of rest, I am inclined to take a more hopeful view, and to make my patient wear a sling and keep his arm at rest. One lesson I have learnt from this case. I think that another time, if the operation is called for, it would be better simply to divide the nerve, or, at any rate, not remove so much as half an inch ; for the distance between the ends has doubtless by the difficulty of union produced the irritative lesion. If the nerve be simply divided, the ends are not likely to completely unite before death or recovery results.

ON A NEW OPERATION FOR DEAFNESS, CAUSED BY OBSTRUCTION OF THE EUSTACHIAN TUBE.

By A. E. CUMBERBATCH, F.R.C.S.,

AURAL SURGEON TO ST. BARTHOLOMEW'S HOSPITAL, AND

W. E. STEAVENSON, M.D. CANTAB.,

IN CHARGE OF THE ELECTRICAL DEPARTMENT OF THE HOSPITAL,

THE great success which has followed the treatment of stricture of the urethra and other mucous passages by electrolysis suggested the idea that an obstructed Eustachian tube might be opened up by the same means. At the latter part of last year several bougie electrodes were made, with the object of carrying this form of treatment into practice. The one shown in this paper, for which Dr. Steavenson is indebted to Mr. Badcock for some suggestions as to its construction, was adopted as the most suitable. (See engraving.) The instrument is made by Mr. Coxeter of

Grafton-street, and consists of a vuleanite Eustachian catheter and an electrical bougie. The bougie is made of a number of fine copper wires about seven or eight inches long, insulated by vuleanite to within an eighth of an inch of their ends. The ends of the wires are soldered into a nickel-plated metal cap. The bougie is small enough to pass along the catheter, and exceeds it in length by about one inch. The handle end of the bougie is provided with a binding screw, to which the insulated copper wires are also attached, for the purpose of connecting a rheophore from the battery. On this end of the bougie an inch is marked off divided into eighths. Each eighth of the inch passes into the catheter as one eighth protrudes at the other end. It is therefore possible to tell, when the catheter is in the orifice of the Eustachian tube, how much of the bougie is in the canal. On the catheter there is a metal ring, or some other mark, as in all catheters, to indicate the position of its end when it is being inserted.

Electrolysis of the Eustachian tube is performed in much the same way as the electrolysis of the other mucous passages which has recently been described. A pad con-

4 British Medical Journal, May 19th, 1888.

nected with the positive pole of a battery is moistened and placed at the back of the patient’s neck. The Eustachian catheter is then passed along the nostril into the tube, and the bougie, already attached to the - pe pole of the battery, is along it as far as it will go, until it meets an obstruction. The circuit is then closed. A galvanometer should be included in some part of the circuit, and the strength of the current increased until a strength of four milliampéres is obtained. A frizzling noise will be heard by the patient in his head, usually likened to the frying | fish; and the operator, by approaching his ear to the catheter, can hear the crackling produced by the frequent breaking of minute bubbles of gas. The electrolysis is kept up for four minutes, and usually before the expiration of that time, if it is possible that the obstruction can be removed, the bougie can be pushed on for a small distance, sometimes for its full length. Generally on the first occasion the Eustachian tube is rather sensitive, but it seems to acquire toleration for the process, and at no time is so much discomfort experienced as might be expected from setting up chemical decomposition in the middle of the head. We have now performed the operation a large number of times, and have not met with any unpleasant experiences, nor has the treatment caused aynes more than very temporary discomfort to our patients. e have tried the treatment in a large number of cases and for different affections of the auditory apparatus, and in those eases in which the deafness has been due to a simple obstruction of the Eustachian tube the results we have obtained have been most encouraging. We are indebted for many of the notes of the following cases to Mr. Badcock, and to Dr. Morrice, Messrs. P. A. Houghton, Fox, and Moberley, assistants in the electrical department.

CASE 1.—J. D——, aged twenty-four, was sent to the electrical department by Mr. Cumberbatch as a case of Eustachian obstruction on December Ist, 1887. He com- poms of deafness and tinnitus, and stated that he had

n deaf in the right ear for five years, and in the left for fourteen months. He was getting worse. A watch could not be heard close to the right ear; no note was made of the distance at which a watch could be heard from the left ear. Electrolysis was performed in the right Eustachian tube as follows: The Eustachian catheter was passed, and the electro-bougie introduced through it down to the obstruction in the tube. The negative — of a Stéhrer’s battery was connected with the electro-bougie and the positive with a pad on the patient’s neck. The current was then gradually applied till four cells were in the circuit, and was mair- tained for five minutes. The bougie electrode was passed three-sixteenths of an inch beyond the distal orifice of the catheter ; this was then withdrawn, and a fine stylet intro- duced in its place, which was passed three-eighths of an inch beyond the orifice of the catheter. After the electro- lysis the patient heard the watch at six inches’ distance from his nght ear. He did not experience much discomfort during the sitting; he described a sensation as of some- thing frying in his head—a crackling and frizzling sound. On . 8th the — again presented himself for treat- ment. The watch was now heard at five inches from the right ear. Hestated that the noises in his head were less, and that his hearing was better. Electrolysis was performed as before for five minutes. The current strength was main- tained at about five milliamperes. The electro-bougie entered the right Eustachian tube three-sixteenths of an inch beyond the end of the catheter. The same “‘frizzling noise” was again heard. The patient heard the watch at nine inches after electrolysis. On Dec. 13th electrolysis was performed in the right Eustachian tube, four cells being employed for half a minute. The current strength was seven milliampéres. The bougie was its full distance along the tube. At the end of half a minute the bougie was withdrawn, as no further obstruction existed. The watch was heard at thirteen inches from the right ear after the sitting. Electrolysis was now performed in the left Eustachean tube, four cells giving a current strength of from five toseven milliamperes. The electro-bougie traversed seven-sixteenths of an inch ; time, five minutes. After the electrolysis the watch was heard two feet distant from his left ear. This patient is a resident in Holland; we have therefore not been able to ascertain his present condition. He promised that if his deafness returned he would come again to this country for treatment.

CasE 2.—Wm. J——, aged sixty, was sent to the electrical department on Jan. 5th, 1888, by Mr. Cumberbatch,

THE LANCET,}

MR. HEWETSON: SEPTIC INFECTION IN MIDWIFERY CASES. [Nov. 24, 1888. 1015

as a case suitable for electrolysis of the Eustachian tube. The patient could hear a watch at a distance of five inches from the right ear. He states that he could hear quite well three weeks ago. A Eustachian catheter was passed along the floor of the left nostril into the orifice of the right Eustachian tube. The electro-bougie was 7 along the catheter and attached to the negative pole of a battery. Two cells were used for five minutes. ter the operation the watch could be heard at seven inches’ distance. On Jan. 9th the patient again attended at the hospital. He stated that he had had no pain or giddiness, but some sing- ing in the right ear. He was again electrolysed, but has not since been to the hospital.

CasE 3.—Emily F——, charwoman, twenty-two, was sent to the electrical department by Mr. Cumberbatch. She stated that a fortnight previously she had had a cold, and that after a fit of coughing she found herself deaf in both ears. On ing the Eustachian catheter through the right nostril, the posterior part was found atly obstructed. On the left side the catheter was ed more easily. The watch was heard at twenty inches’ distance from the right ear and twenty-four inches from the left. A catheter was passed into the right Eustachian orifice, and an electro-bougie three-quarters of an inch beyond the end of the catheter. Electrolysis was performed, four cells being employed for four minutes. The watch was heard at a distance of thirty-six inches from the right ear after the electrolysis. The patient only presented herself for treat- ment upon this one occasion.

CasE 4.—Mr. R. C——,, a private patient of Mr. Cumber- batch, suffering from deafness with obstruction of both Eustachian tubes, was first electrolysed on April 5th, 1888. On May 4th electrolysis of the left Eustachian tube was performed, and occupied four or five minutes, the current strength being six milliampétres. The bougie entered the tube for seven-eighths of an inch. On May 14th it was stated that he had been rather more deaf for three days after the last operation, but had since then gradually improved. He had had a bad cold. Before electrolysis ‘was again commenced he could hear a watch at five locas” distance from the left ear. The catheter was passed into the left Eustachian tube, and a current of four milliampéres used for five minutes. After electrolysis, the same watch could be heard at twelve inches’ distance. A catheter could not be introduced into the right tube. Since the last date . the patient was electrolysed six times, with gradual improve- ment in hearing.

CASE 5.—Mary Anne R——, aged forty-one, domestic servant, was sent to the electrical department by Mr. Cumberbatch on June 12th, 1888. The patient complained of deafness and tinnitus. The left ear was much the worse of the two. She had pain in the left ear. The noises and pain sometimes kept her awake at night. The noises re- sembled the singing of a boiling kettle, and were constant in the left ear. The watch was heard only when almost touch- ing the left ear; it was heard against the skull much better on the right than on the left side. On the occasion of her first visit the patient was galvanised through the left ex- ternal auditory meatus, the positive pole being placed in the meatus, and the ane in the form of a moistened oar to the right side of the head. On June 29th the patient had not improved. Electrolysis of the Eustachian tube was mame four cells of a Stéhrer’s battery being employed

or four minutes. The Eustachian catheter was introduced into the left tube, and then the electro-bougie passed three- quarters of an inch. On July 6th it was reported that there had been no improvement in the hearing of the left ear. Electrolysis of the left tube was performed. During the sitting the bougie was one inch into the tube. The tient heard the watch at a distance of six inches from the eft ear after the electrolysis; she had heard it on contact only before. On July 13th she was again electrolysed in the left Eustachian tube. The improvement in hearing was maintained.

CASE 6.—-Thos. H——, aged fifty-five, a butcher, suffering from auditory vertigo, was sent to the electrical depart- ment by Mr. Cumberbatch on July 16th, 1888, for treatment by electrolysis. The patient complained of great noises and of deafness, chiefly in the left ear. He com- — also of attacks of giddiness. He had suffered from

eafness and tinnitus for twelve months, and from giddiness for the last six months. The watch was heard at seven inches’ distance from the right ear, at barely one inch from the Electrolysis of the left Eustachian tube was performed,

four cells being employed for four minutes ; the bougie was passed five-eighths of an inch. The patient was ordered a mixture containing bromide of potassium and dilute hydro- bromie acid. On July 23rd the patient reported that he had suffered from less noise in his left ear and in his head than hitherto, and he had had two attacks of giddiness. The left Eustachian tube was again electrolysed, the electro-bougie passing fifteen-sixteenths of an inch beyond the orifice of the catheter. On July 30th the patient re- a pe that he had been better during the last week, had

ad no giddiness, but a good deal of noise in his head. He was electrolysed as before. On Aug. 13th the tinnitus had been very much better, and the improvement in hearing had been maintained; but he had had some giddiness. Electrolysis was performed as before. He has not since attended at the hospital.

CasE 7.—Geo. B—, fifty-two, was sent to the electrical department by Mr. Cumberbatch on July 23rd, as a case suited for electrolysis of the left Eustachian tube. The patient stated that he had heard perfectly well up to six weeks previously. He then found suddenly that he was deaf in the left ear. He had lately had noises in the left ear, but not very. loud. He could hear a watch at five inches’ distance from the left ear. He had suffered from chronic pharyngitis, and does so still. The left Eustachian tube had been inflated by Politzer’s bag in the aural de ment, when he heard better for a short time. Electrolysis of the left Eustachian tube was performed; the catheter

easily. Four cells were used for four minutes; the electro-bougie passed seven-eighths of an inch. The patient was subsequently electrolysed in the same manner on July 30th and Aug. 13th; on each occasion he stated that the hearing was improved, and the noises in his head were less. On Aug. 27th he again presented himself for treat- ment. The watch was heard at one foot from the left ear. Electrolysis was performed, four cells of a Stihrer’s battery, giving a current strength of five milliampéres at the maximum, being employed during four minutes.

Notes by Mr. CUMBERBATCH.—Our experience is at present too limited to be able to say what cases of chronic catarrh of the middle ear are most likely to be benefited by this new method of treatment. That strictures of the Eustachian tube, which do not yield to the ordinary methods, can be cured by the use of the electric bougie we have proved. In many cases of chronic catarrh, with obstruction of the Eustachian tube, there is no actual ankylosis of the ossicular joints ; and in such case restoring the patency of the tube, and thus relieving the pressure on the membrana tym-

ani and the chain of ossicles, must act beneficially on the

earing. In cases also where the catarrh has spread to the labyrinth, the distressing tinnitus, when due to circulatory disturbance rather than to any lesions of the nervous elements, is likely to be removed. When auditory vertigo is caused by undue pressure on the labyrinth owing to strong retraction of the membrana tympani, it is ible to relieve it (of course by restoring the patency of the Eustachian tube) by means of the continuous current, as has been proved several cases which have been thus treated. In conclusion, I may add that, if after three or four trials a patient experiences no benefit, the probability is that further treat- ment by this method will be useless.

THE DANGER OF SEPTIC INFECTION ARISING FROM NASAL AND AURAL DISCHARGES IN MIDWIFERY AND SURGICAL PRACTICE:'

By H. BENDELACK HEWETSON,

SURGEON TO THE OPHTHALMIC AND AURAL DEPARTMENTS OF THE GENERAL INFIRMARY, LEEDS.

Some little time ago attention was drawn by Sir Spencer Wells, I believe, to the case of a now celebrated ovariotomis‘, who, despite all his constant care and watchfulness, continu- ally found his operations followed quickly by a fatal result. I think it was suggested to him that this fatality might arise from some personal condition, and at length, on application

1 Read before a meeting of the Leeds and West Riding

Medico- series of

Chirurgical Society, Oct. 12th, 1888. A contribution to the papers on “‘ Antiseptic Midwifery.”

1016 THE LANCET,)

HOSPITAL MEDICINE AND SURGERY.

(Nov. 24, 1888.

to a skilful dentist, a suppurating molar tooth, which was removed, revealed the cause of the fatality, and with the removal his success began. Dr. Matthews Duncan has also quoted one or two cases of medical men suffering from some form of rhinorrhcea, whose attendance in the lying-in chamber was particularly disastrous to their patients. But [donot think . thatsuflicient stresshas yet been laid on this very broad ques- tion, asa whole, inregard to septic infection generally. Every- one in Leeds aha the case often quoted, in which three leading members of the profession several years ago attended the post-mortem examination of a case of peritonitis, and each afterwards within the next twenty-four hours attended a labour, with a fatal puerperal fever in each instance. My attention has recently been very seriously drawn to the great danger which attends the parturient patients of those who are the subjects of even a slight otorrhwa, or in whom there is some nasal discharge of an offensive nature. The opportunity of bringing the facts before the Leeds and West Riding Medico-Chirurgical Society has been gladly accorded to me by the practitioners whose ailments t have treated, and will form the subjects of this paper. : Some time since I was consulted by.a medical man for an affection of the left ear. He heard badly on that side, and suffered from great depression of spirits ; he was pale and anxious-looking (though naturally he was bright, cheerful, and energetic), and spoke despondingly of his future and his pues. I found that there was a small perforation of the membrana tympani, and a thick semi- solid discharge lay on the floor of the meatus, but never appeared externally ; but it was, when disturbed, horribly esas He told me that, in order to find out the cause of his unexplained ill health, he had had all his drains overhauled, and also had had the drinking water looked to, with negative results. J at once explained to him that the cesspool in his case was in his ear, and that probably in a short time a course of antiseptic treatment would neutralise the chronic absorption of the septic material, which was so exceedingly depressing to him, and cure his symptoms, I asked him if he was aware of the otorrheea, and he assured me that the deafness was the only thing which troubled him. I wag exceedingly anxious to learn from him the results of his large midwife and with carefully weighed words | approached the subject. This ended in an exceed- ingly painful expression of feeling, which I need not dwell upon., Suflice it to say that his misfortunes in this depart- ment puerperal septicemia were very constant, and also that many who recovered only did so after passing evidently through an attack of septicemia. It was at once evident to him that his ear trouble, which constantly caused irritation and consequent—often unconscious—scratching for relief, was the obvious cause of much of the puerperal trouble which he related tome. The treatment which we adopted very quicky set matters to rights, and I am glad to say that, though he was obliged to change his practice, he has done exceedingly well in midwifery practice ever since. His health also quickly returned. I may add that it is his expressed wish that these notes should appear in this form iain the Society.

The second case which I have to report in support of this subject occurred in the practice of a medical friend of mine, and it was the quoting of the above case in conversation to him which suddenly threw light on a case of puerperal fever which ended fatally in his practice the week before. The facts are these: My friend had engaged a qualified assistant, and, being called away, the assistant was sent to an important midwifery engagement some distance off, and all went well until the end of the third day after delivery. Puerperal fever set in, with a rapidly fatal termination. I was asked to examine the assistant, and I found that he suffered from tertiary syphilis, disease of the nasal septum, with a most offensive discharge, and foul breath. He was obviously & danger to any lying-in woman, and I advised that he should be completely rid of his trouble before he again played his part in general practice.

These cases point strongly also to the possibility of nurses suffering from aural or nasal discharges being the media of infection. I have seen three instances of hospital nurses working constantly amongst the most important surgical cases, quite innocent of the fact, until told them, that they were standing dangers to the cases under their ch i each instance they were removed from active work until

the otorrhwa had ceased. I am exceedingly glad to have been able, as it were, to dovetail this paper into the list of

papers before us to-night on antiseptic midwifery, for, how- ever dangerous such conditions — be when occurring in association with general surgery, the increase of danger must be much enhanced when in relation to the actively absorbent conditions of the puerperal state.

Leeds.

OF HOSPITAL PRACTICE, BRITISH AND FOREIGN.

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor- borum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morbd., lib. iv. Proeemium.

ST. MARY’S HOSPITAL. THREE CASES IN WHICH GASTROSTOMY WAS PERFORMED ; REMARKS. (Under the care of Mr. PEPPER.)

Ir will be seen from Mr. Pepper’s remarks on these cases that he is an advocate for the performance of gastrostomy at a comparatively early stage, when dysphagia is dependent on malignant stricture of the csophagus, and there is a feeling amongst surgeons in favour of this. A fuller com- prehension of the principles on which the operation should be conducted, improved methods of carrying them into practice, the postponement of the incision into the stomach itself until a few days have elapsed, and the employment of antiseptics, have rendered the results of the operation far more satisfactory than was considered possible at the time of its introduction. Provided the patient be in a fair condition of health, a good prognosis may now be given both as regards recovery from the operation and the future relief afforded by it; but if, as in the second case, the health be much deteriorated, a fatal result may be fre- quently expected. Another argument in favour of its early employment is to be found in the following sentence : ‘‘In some the patients [speaking of recorded cases] sank from inanition, apparently from lack of power to digest and assimilate the food introduced into the stomach.”? It will be noted that Mr. Pepper made a change in the usual method of suturing the stomach to the wound, the result aimed at being, however, the same as that attained by the method of double suturing employed by Howse,’ or the use of acupressure needles* or harelip pins by others.

CASE 1.—Maliqnant stricture of the wsophagus ; gastros- tomy ; recovery. William wo cmt sixty-eight, a

lasterer by trade, was admitted under Dr. Broadbent on

arch 23rd, 1888, complaining of pain across the lower part of the chest and constant vomiting. About Christmas, 1887, he began to suffer from pain in the lower part of the chest. In Foscney he first had pain during deglutition, and soon afterwards he became unable to swallow solid food, which rgitated from the esophagus half an hour after being taken, and since then he has lived only on fluids. On examination the abdominal walls were found to be retracted and flaccid. Liver dulness from seventh rib to two inches below margins of ribs, and extending on left side nearly to nipple line. Heart and lungs normal. No tumour could be detected. The vomit was not mixed with gastric juice. On April 11th he was transferred to the surgical wards, it having been decided to perform gastrostomy, as he was then unable to take even fluid nourishment. Attempts to pass an esophageal bougie had been made, but without success, an obstruction existing at the crossing of the left bronchus. Temperature normal. No family history of cancer, and no assignable cause for the incidence.

On April 13th, chloroform having been administered an incision three inches long was made lel to an a finger’s breadth from the cartilages of the eighth ninth, and tenth ribs on the left side. The abdomi

1 Holmes’ System of Surgery, vol. i., p. 801. Practical Surgery, art. Gastrostomy. 3 Verneuil

2 Heath's Dictionary of

THE LANCET,)

HOSPITAL MEDICINE AND SURGERY.

[Nov. 24, 1888. 1017

muscles were then divided and the peritoneum aoe After all bleeding had ceased, this was opened and the edges stitched to the skin with silk sutures. The stomach having been found, its anterior surface was united to the edges of the wound by means of about sixteen silk sutures passed through the superficial coats of the stomach, the parietal peritoneum, and the abdominal wall. The sutures were left long and the ends clamped. In addition, two long silk threads were passed through the peritoneal and muscular coats of the stomach, and the ends knotted together. The wound was dressed with iodoform, per- chloride of mercury gauze, and wood-wool pads. After the operation the patient was — and did not complain of pain. His temperature fell to 96°. Two enemata were ordered to be given alternately every six hours: the tirst composed of two ounces of peptonised jelly and half an ounce of brandy; the other of one ounce and a half of strong beef-tea, the yelk of one egg, and half an ounce of brandy.

April 14th.—The patient has slept a little during the night, and does not complain of pain. Temperature last night 98°; this morning, 101°. At 11 A.M., he not having slept during the morning, an eighth of a grain of morphia was hypodermically.

= progressing well; no pain. Temperature normal.

17th.—Dressing removed; wound healthy. A _ small apatite made into the stomach between the two silk threads before mentioned. Care was necessary to avoid wounding the posterior wall of the stomach, as the viscus was rans. A very soft No. 10 catheter was then intro- duced, and five ouncesand ahalf of a mixturecontaining milk, peptonised beef-tea, brandy, and three drops of hydrochloric acid introduced. The catheter was secured by a piece of strapping, and the wound dressed with a pad of wool. No anesthetic was given, and the patient felt no pain. He was ordered to be fed with two ounces of peptonised beef jelly, two ounces of pancreatised milk, one ounce of brandy, and the yelk of one egg, to be injected into the stomach every four hours, alternating with nutrient suppositories by the rectum.

From this time the patient made an uninterrupted recovery, the temperature not rising above normal and there being no vomiting. On April 25th all the sutures were removed, and on the 27th the food was increased to two ounces of peptonised beef jelly, six ounces of pan- creatised milk, and one egg. He was discharged on June 5th, from which time to the date of his death on July 26ti he came to the hospital almost daily. There was complete relief from the distress caused 4 ineffectual attempts at swallowing, and he regained strengt and increased in weight. On the last-mentioned date he was “‘ taken in a fit,” and died in about twenty minutes. At the necropsy on July 28th it was found that the growth (epithelioma) had ulcerated into the left bronchus, and that a quantity of blood had passed thereby into the air passages, death having been evidently caused by suffo- cation.

CasE 2. Malignant stricture of the tomy ; death.—William P——, sixty-nine, a labourer, was admitted on June 5th, 1888. He stated that in October, 1887, he had a bad cold, and his throat became sore and painful, and that it hurt him when he swallowed. Under treatment the pain was for a time relieved, but the difficulty in swallowing inc , and he had pain shooting up to both his ears. Two months before admission he could only swallow minced beef, and even then had to wash down the bolus of food with fluid. Later on solid food rgitated, and he was reduced to fluid diet. Two or three weeks before he came in he noticed some hard lumps beneath his jaw, and, as he expressed it, ‘‘ something used to burst in

is throat, and in ease ” some stuff up a lot of phlegm used to come, and some black blood.” This happened three times. He never suffered much pain. No history of syphilis, impaction of a foreign body in esophagus, or swallowing of corrosive fluid could be obtained. No family history of cancer.

Condition on admission.—The patient is unable to swallow, and he localises the obstruction at a spot immediately on notch. There is no — tonsils,

ryng ypus, or post-nasal growth. ere are a in the upper part of the neck, but none lower down. Breath very fetid. Urine normal. A bougie

us ; gastros-

could not be passed much beyond the cricoid eartil and on w.thdrawal was covered with blood. 7

June 8th.—Weight 10st. 2lb. Fed on nutrient enemata every four hours, and two hours after each enemaa nutrient

su tory.

The first stage of the operation of gastrostomy was per- formed on June 8th. After the operation the temperature fell to 97°, but soon rose to normal and remained so until the 12th. His general condition was good. The enemata were retained. Once a day he had a gruel enema to clear out the lower bowel.

On the 12th the operation was completed without an anesthetic. A No. 12 soft catheter was introduced, and four ounces of a mixture of milk, egg, and brandy injected. It was noticed that there was a good deal of redness around the wound and tension on the sutures, so the latter were removed and the wound supported with strapping and again dressed antiseptically. Four hours later, on removing the dressing to feed him, a small piece of omentum was found protruding through the wound. Feeding by the stomach was discontinued, and nutritive enemata given every three hours, each alternate enema containing twenty minims of tincture of opium. The _—— passed a restless night and had pain in the right iliac region. On the morning of June 13th the dressings were removed, and it was found that the adhesions had al! broken down and a large piece of omentum was protruding, which was covered with the partly digested contents of the siomach. As it was found impos- sible to reduce the omentum, it was ligatured close to the abdominal wound and removed. No further operative _——- was deemed advisable in the then hopeless con- ition of the patient. The patient gradually sank, and on the following day was in a semi-comatose condition ; the enemata were not retained and he died in the evening.

Necropsy.—Body of a well developed and muscular man. Gastrostomy wound in the left hypochondriac region; edges gaping except at upper and lower angle, where they are

rawn together with silk sutures; on dividing the sutures the edges gaped. Woundsuppurating. No gut attached to peri- toneal edges of wound, the stomach having sunk backwards and upwards beneath the left ribs. The colon lay imme- diately beneath the wound, though not in contact with the edges thereof. On opening the abdomen the coils of intestine were seen to be greasy, flecked with lymph, and injected. An opening into the stomach had been made on the anterior or upper surface four inches above the pylorus (measurement taken after opening). Stomach contracted ; mucous membrane injected. (Ksophagus: A malignant epitheliomatous growth, completely encircled the tube, commencing above at the lower border of the cricoid carti- lage and extending downwards for a distance of three inches in one continuous mass, and below this point were numerous discrete nodules of growth in the submucous tissue as low as the cardiac orifice. The walls of the pharynx were in- filtrated by growth, which was ulcerating and continuous with that in the esophagus as high as the upper border of the thyroid cartilage. A slightly elevated nodule of growth appeared in the posterior wall of the trachea on a level with the first and second rings, which was continuous with the cesophageal growth ; lower down the trachea several other nodules appeared in the submucous tissue. The lymphatic glands on the left side of the esophagus were infiltrated, and those in close proximity to the main mass of the wth breaking down; these formed a mass lying mainly neath the sterno-clavicular articulation. The right = was cedematous and congested, the left collapsed an emphysematous at the edges. There was slight atheroma of the mitral valves; otherwise the heart was normal. The kidneys were slightly granular.

Case 3. Stricture of pase. H—, aged sixty-five, was admitted to the medical wards on October 11th, on account of pain in the epigastric region and difficulty in swallowing. Two months ago he first noticed a slight difficulty in a and he also had pain in the epigastric region, which was increased on _——. Shortly afterwards he commenced to vomit all food, both liquid and solid. The pain, diffi- culty in swallowing, and vomiting have e on in- creasing, and he has me emaciated and weak. A blacksmith by trade, he has — been strong and healthy, and there is no history o eyphiilis, hereditary cancer, or injury to the csophagus. ter admission he

was kept in bed and put on a liquid diet, and the vomiting, although still continuing, was not so frequent. The circu- latory system was normal. On Oct. 16th Mr. Pepper first

saw the patient in ——. with Dr. x

Maguire, when it

PATHOLOGICAL SOCIETY OF LONDON.

(Nov. 24, 1888.

1018 THE LANCET,)

gastrostomy.

The operation was performed in two stages, as in the eases recorded above—the first on Oct. 24th, and the second on Oct. 30th. Between these two dates he was fed every four hours by nutrient enemata as in the other cases, ice only being allowed by the mouth. There was no rise of temperature, and, with the exception of slight pain in the neighbourhood of the wound, he did not seem to be affected by the operation. After the completion of the operation he was fed partly through the fistula and partly by enemata until Nov. 2nd, when the latter were discon- tinued, and he was fed entirely by tke stomach. On Nov. 10th he was able to sit up in , the wound being in a perfectly healthy state and the patient’s general con- — improving. On the 2Ist he was up and about the

ard.

Remarks by Mr. Perrer.—When once the diagnosis of malignant disease of the csophagus is established and swallowing seriously interfered with, it is better to perform gastrostomy without delay, and not wait until the chances of recovery from the operation are minimised by the patient’s exhaustion, the alternative course of passing bougies for the purpose of feeding being irksome to the surgeon and painful and dangerous to the patient. The statistics of gastrostomy are not to be relied upon as_ afford- ing an argument for or against the advisability of performing the operation in any particular case, inas- much as many of the reported cases have only been operated upon when there was little or no hope of real and rotracted gain being obtained. In any case gastrostomy 1s to be tm erred to wsophagostomy, whilst it is the only practicable operation when the disease is situated below the commencement of the gullet. The stitching of the parietal oS ogee to the skin is advocated, as it serves the

ouble purpose of restraining bleeding from the divided structures, and gives a broader surface for the attachment ef the stomach, and so more extensive adhesions. On the day before the first stage of the operation the lower bowel should be emptied by a gruel or olive-oil enema, irritant injections containing soap, turpentine, &c., rendering the rectum unable to afterwards retain nutrient enemata. A sharp, narrow, long-bladed knife should be used for opening the stomach, as a considerable depth has to be traversed, and no tension should be put on the adhesions as the knife is carried through the walls of the stomach; no force should be employed in passing the feeding tube, the size of a No. 12 par or ing The guiding threads previously men- tioned are useful in directing the yp of the knife, as by the time when the stomach is opened the exposed portion has lost its glistening appearance, and may in some measure have altered its relation to the edges of the wound. For the preparation of the above reports and for many valu- able suggestions I am indebted to Mr. T. H. R. Crowle, surgical registrar to the hospital.

CIVIL DISPENSARY, PISHIN, A CASE OF LATERAL LITHOTOMY IN AN AFGHAN BOY.

(Under the care of Surgeon P. J. DAMANIA, Indian Medical Service.)

WHEN a prominent place is now accorded in surgery to suprapubic lithotomy to show its superiority over the opera- tion of lateral lithotomy, it is fair that even a solitary case that can be adduced in favour of the latter operation should be published.

An Afghan boy, aged thirteen, was brought to the Civil Dispensary at Pishin, with symptoms of stone in the bladder. About four years ago he complained of pain on micturition, which gradually increased to such an extent that he was unable to sit up without having pain in the urethra. The face and feet were edematous. It was difficult to get at the history of the swelling. The specific gravity of the urine was 1013; a large quantity of albumen was present. It was very nearly the colons of chylous urine from the admixture of pus and mucus. On passing a sound into the bladder a stone was detected. As dysentery supervened during his stay in hospital, he was operated ona little later, when he had recover

from that complaint. was administered and lateral lithotomy per-

formed in the usual way on Oct. 2nd, and a uric acid calculus, weighing 263 grains, extracted. The patient was placed on his bac with stretched legs. Urine flowed from the wound on the first day of the operation, but from the second day it passed entirely through the urethra. On the third and fourth days the urine continued to pass through the urethra, and not a drop of it from the waned Taking advantage of this entire flow of urine through the urethra, iodoform was sprinkled freely on the wound, which began to heal rapidly under it, and was entirely closed on the fifth or sixth day after the operation, when the patient was able to sit ap in bed. After the opera- tion the swelling of the face and feet began to lessen, but the quantity of albumen in the urine remained the same. Throughout, the temperature was normal after the operation. The bowels were moved on the fourth day. About a fort- night after the operation the urine commenced to get clearer and the quantity of albumen was very small. After the operation morphia and quinine were given internally, and for a few days bicarbonate of potash with hyoseyamus. On Oct. 17th he left the Dispensary quite cheerful, with total disappearance of the swelling of the face and feet.

Medical Societies.

PATHOLOGICAL SOCIETY OF LONDON.

Peculiarities in Hernial Sacs and their Contents.—Disloca- tion of Shoulder without Rupture of Capsule.—Galvano- puncture in Aortic Aneurysm.—Cancer of Pancreas.— Acute Intestinal Obstruction.

An ordinary meeting of this Society was held on Nov. 20th, Sir James Paget, President, in the chair.

Mr. Lockwoop exhibited a number of Specimens to illus- trate Pecnliarities in the Construction and Contents of Hernial Sacs. Two of the specimens showed conditions which predisposed to the formation of infantile herniz. In one, which was obtained from an adult, whilst the tunica vaginalis had formed in the usual way, the rest of the

rocessus vaginalis had remained patent as far as the internal ring, where it was occluded. Immediately behind its upper part, however, there was a small peritoneal pouch, similar to, but smaller than, the true sac of an infantile hernia. The second specimen was of the same nature, except that the truehernial sac was longer than in the preceding case, and inextricably confounded with the fibres of the internal cremaster. An interesting point in the history of this specimen was that theinfant from which it had been obtained had been operated upon by Mr. Cripps, and the front sac, that formed from the upper part of the processus vaginalis, opened. No hernia was discovered, although some fluid was evacuated, and the patient died, as it subsequently appeared, of an intussusception of the small intestine. In neither of these cases was any gut found in the hernial sac. The third specimen demonstrated a number of rare and interest- ing facts. After the abdomen had been opened great difli- pon was experienced in finding the vermiform appendix, and it was thought to be absent. However, it was dis- covered hidden away in a serous pouch which lay behind the cecum, thus forming a retro-peritoneal hernia of the vermiform appendix, clearly a very rare and unusual con- dition. In addition, there was an ordinary hernial, sac of considerable dimensions whose mouth was external to the deep epigastric artery, whilst its fundus lay upon the tunica vaginalis, which was quite normal. Towards the inner side of the hernial sac there was a second serous sac, larger than the tunica vaginalis itself, and quite isolated and cut off from the rest of the peritoneum. It seemed comparable to the sac of a <7 of the cord, but, of course, contained no fluid. The hernial sac had, when found, nothing within its mouth. A very la lica vascularis ran upwards from it to unite with the end of the mesentery, close to the cecum. The plica was joined by another foid which ran transversely across the fundus of the bladder. The isolated pouch found in this instance seemed similar to one recently described by Professors Bennett and

Cunningham, and which they considered to have been drawn

down by the gubernaculum at the time of the formation of

the processus vaginalis. The persistence of the plica vascu- laris and the relations of the vessels to the ial sac

was ‘decided that, as only a very small bougie could | passed through the stricture, which was situated at the cardiac orifice of the stomach, it was advisable to perform | _ |

THE LANCET,]

PATHOLOGICAL SOCIETY OF LONDON.

[Nov. 24, 1888. 1019

indicated that the anomalies were due to a developmental defect. Ventral hernia formed by an appendix epiploica: This hernia was situated in the left linea semilunatis, a little below the level of the umbilicus. At first it seemed merely a subperitoneal lipoma, but it was in reality one of the appendices which protruded through an opening in the peritoneum into an excessively thin hernial sac, to which it was adherent. Where this sac pierced the linea semilunaris there was a distinct ring, like the umbilical ring. The mode of formation of this protrusion seemed quite inex- plicable. There was no ~ of any previous wound, and the ome appear so late that it could hardly have been due to a developmental defect. Caleareous body in the sac of a femoral hernia: This specimen was found in avery old woman. The sac was excessively thin, and contained a laminated calcareous mass more than half an inch long and more than a quarter of an inch thick and very hard. It consisted of caleareous matter, with some fibrous material, and had probably originated in the peritoneal cavity in a fibrinous concretion, which had afterwards calci- fied. Appendix vermiformis, incorporated with the back of a hernial sac: In this specimen a very long vermiform appendix ran down the centre of the hinder wall of the sac of the hernia. The mouth of this sac was capacious and contained the eecum. Upon the outside of the back of the sac the spermatic vessels ran exactly parallel and opposite to the vermiform process. The latter had no mesentery except at its lower end. The hernial sac and tunica vaginalis were separate and distinct. The vermiform process had been dragged down in the forma- tion of the sac, probably by the small intestine, and the cecum had followed. Mr. kwood said that he showed these specimens because of their rarity, and in the hope that light might be thrown upon their peculiarities.— Mr. JONATHAN HUTCHINSON, jun., had found a con- cretion as large as a walnut in the sac of a femoral hernia, and its origin from a calcified epiploic appendage was proved by a second cretified appendage being discovered still attached by a peduncle to the large intestine. He re- = the formation of secondary isolated sacs, in some

ernie at least, as due to a pease of very chronic local peritonitis.—Mr. TREVES said that in every instance in which a cecum or appendix was found in a hernia there was a true sac. The appendix vermiformis represented the long, twisted ceecum of marsupials, and where the appendix was long the cecum was small. In some cases where the small intestine had a very large sac, the posterior wall of that sac was sometimes formed of peritoneum stripped from the cecum. If a hernia contained an epiploic appendix, the latter was always adherent, the adhesion being often ex- — by the fact that the appendix contained a false

iverticulum, in which fecal material lodged and set up inflammation. In two or three cases of non-malignant com- munication between colon and bladder it appeared to have resulted in this manner. The retro-czcal fossa was formed by a further movement downwards of the colon, after what should have been its arrest in the iliac fossa.—Mr. GODLEE, referring to the development of secondary sacs, described two cases illustrating their formation. A little boy had an undescended testis, followed by a hernia, and a truss was adapted to om the hernia up and the testis down; a hydrocele of the funicular process developed, which re- quired treatment by injection. The second case was in an adult, with i ucible omental hernia associated with hydrocele, a valvular opening existing between the two sacs. In both cases the septa were probably formed by very chronic inflammation.— Dr. Mott showed a very small cecum with an oe 6? in. long taken from a man aged fifty-one, who died of chronic Bright’s disease ; the appendix ended in a pouch in the anterior part of the iliac fossa, which had been described as infra-cxecal.— Mr. Pirts thought the undue length of the vermiform ——— predis to cecal hernia, and he referred to three cases (children) on which he had operated and found this condition present; in all, the cecum was free, and there was a complete sac.—Mr. TREVES, referring to the fossa in Dr. Mott’s case, said it had been descri as the “‘ fossa iliaca subfacialis.” The retro-czecal fossa was certainly un- connected — a bloodvessel, but in Dr. Mott’s case one appeared to resent.

oid was relativel

masses from epiploic appendages. He ed with upon chronic inflammation as a cause of separate sacs, whereas the pointed shape of some

of the diverticula suggested traction by muscular fibre. The long vermiform appendix could rarely predispose to hernia, though it might get entangled in the closing pro- cessus vaginalis.

Mr. D’Arcy Power showed for Mr. Claude Evill an interesting case of Dislocation of the Shoulder without Rupture of the Capsule. A man aged sixty-nine fell a distance of eighteen feet on to his right elbow and side, sustaining thereby a compound T-shaped fracture into his elbow and a dislocation of his shoulder. The dislocation was easily reduced, but the patient died twelve — after admission to hospital. At the necropsy the head of the bone was found to be in position, but the capsule of the joint was intact. It was lax, and its attachment to the anterior border of the glenoid cavity was slightly raised, but was still quite continuous with the periosteum. opening the capsule there was a well-marked groove on the

terior surface of the head of the humerus. Mr. Power rew attention to the fact that Mr. Eve had shown an almost identical case before the Royal Medical and Chirurgical Society in 1880, and he agreed with him in believing that the groove was produced by the forcible impact of the humerus against the anterior margin of the lenoid cavity. He had no doubt that the dislocation had en complete, and that the case could not be looked upon as an instance of subluxation.—Mr. W. ADAMS thought that a traumatic dislocation of the shoulder without laceration of capsule could only occur forwards ; he did not think such a lesion could happen at the hip at all. In con- genital hip cases the condition of parts was very different, the acetabulum never having been formed, and there bein instead a flattened surface more comparable with the glenoi cavity. In one case of dislocation of the hip from effusion into the joint during fever he had found a lacerated capsule. — Mr. BowLby said that econ | both cases referred to by Mr. Power presented the signs of ordinary subcoracoid dis- placement.—Mr. PowER replied that the only four recorded cases were either subcoracoid or subclavicular.

Dr. RALFE exhibited the Sac of an Aortic Aneurysm after Galvano-puncture. The patient came under observation in Sept. 1887, when the aneurysm had already made its way through the costal cartilages to the right of the sternum. The skin was of a livid hue, and the pulsation was extreme. Death from perforation was expected shortly to ensue, but after the first operation the ME pasy 2a of the disease was decidedly arrested, and he lived on for nearly eleven months, and did not die till August of the present year. The first operation, which was performed by Mr. Mansell-Moullin, as were the su uent ones, was followed by subsidence of the swelling, whilst the tumour became harder and the skin lost its livid hue. The improvement lasted some time, but shortly the pulsation returned and the patient was troubled with a violent paroxysmal cough. Galvano- puncture was again resorted to, and again the pulsation diminished and the tumour became harder, whilst the cough disappeared. In all, galvano-puncture was _per- formed thirteen times, and always had the effect of giving the patient relief. Finally, after nine months of treatment, a pustule appeared over the seat of a puncture, and from that time adhesion took place between the tumour and the skin, and perforation slowly ensued. But, instead of a sudden rupture with profuse hemorrhage, comparatively slow oozing took pace, and the patient jos ao os sank from weakness, without experiencing shock or pain. Dr. Ralfe claimed for galvano-puncture, where suitable, (a) prolongation of life in rapidly progressive cases ; (b) relief of pain, of undue pulsation, and of paroxysmal

cough; (c) the probability of an almost painless death, owing to — oozing from the thickened sac, instead of sudden rupture, which, if it occurred internally, must be intensely agonising for the short interval the patient survived. Mr. W. H. KESTEVEN related a case of peo oe | Cancer 8

of the Pancreas causing Biliary Obstruction, and showed a specimen taken from the body of his patient. There were several recurrences of abdominal pain with clay-coloured motions, the urine was stained with bile, and later contained quantities of sugar, which disappeared under dietetic treat- ment. There was albuminuria during the last few weeks of life. The chief interest in the case lay in its obscure nature, the actual cause of the jaundice and the other symptoms indicating biliary obstruction not being rendered clear till after death. The head of the pancreas was then found to be the seat of cancerous disease, which had led to compression of the common bile duct; the latter on the hepatic side was largely distended, as was the gall bladder. No other

ICKWOOD was g to irect ev

1020 THE LANCET,)

MEDICAL SOCIETY OF LONDON.

[Nov. 24, 1888.

organ was found diseased. Primary cancer of the pancreas was rare, and had only lately been conclusively proved to exist. Some of the symptoms in the case related might have some bearing on the question of the connexion between the pancreas and diabetes which had lately been mooted.— Dr. COUPLAND theaght that primary cancer of the pancreas was not rare; it was certainly more common than secondary cancer. Thus the pancreas resembled the breast and uterus, and differed from the liver.—Mr. RoGER WILLIAMS had found the proportion of primary cancer of the pancreas to be 1 to 500 of all kinds of camat.

Dr. PERRY brought forward two cases of Acute Intestinal Obstruction. In one specimen a loop of small intestine, a few inches above the ileo-cecal valve, had passed through a ring formed by an adhesion between the tips of two adjacent appendices epiploice arising from the sigmoid flexure of the color. In the other case the evidence was circumstantial. The patient had signs of intestinal obstruc- tion; laparotomy was done, but at the operation the surgeon tore through a band low down on the left side of the pelvis, which he was unable to bring into view. At the post-mortem examination, a piece of ileum, thirty inches in length, was found blackened and with marks of constriction upon it at either end, and two adjacent appendices from the sigmoid flexure were seen to have their contiguous margins much congested, while their tips showed signs of laceration. Dr. Perry remarked that it was rare for intestinal obstruc- tion to be occasioned by appendices epiploica, and still more rare for it to be produced by appendices adherent to each other. The only case exactly resembling the present one, which Mr. Treves had mentioned in his monograph on Intestinal Obstruction, was a case reported to the Society in 1861 by Mr. Holmes. In discussing the pathology of such obstructions, Dr. Perry said that it might possibly be a normal condition for appendices epiploice to be united along their adjacent edges. They might also become adherent by inflammation, and whether naturally coherent or cohering as the effect of inflammation, the thin membrane which united them might become perforated and a piece of intestine find its way through the opening so made. On the other hand, the tips only of the appendices might have become attached to each other as the result of a slight degree of adhesive peritonitis. As bearing upon this point, Dr. Perry observed that the adherent appendices sprang in each case from the sigmoid flexure of the colon, and were therefore in the immediate neighbourhood of the pelvis; that the specimens shown were from women, in one of whom the adhesion of the omentum to the abdominal wall was good evidence of old peritonitis ; and that in Mr. Holmes’s case,

‘where the patient was a man, he had suffered from double inguinal hernia. It had been suggested that small, false diverticula might project into appendices epiploice, and were apt to lodge irritating matter of various kinds. Inflammation might thus be set up in the pouch and spread to the appendix, causing a limited peritonitis and an isolated adhesion ; but this explanation would not apply to the present cases, in which no “ distension ” diverticula were found.

The following card specimens were shown :—

Dr. Morr: Anomalous Appendix Ceci.

Mr. BLAND Sutton: (1) Spina Bifida; (2) Supernumerary Legs in Frogs; and (3) Supernumerary Mamme in Monkeys.

r. TARGETT: Dermoid Cyst near Knee.

Dr. Ropinson: Phosphatic Concretion from a Recto- vaginal Fistula.

Sir JAMES PAGET announced that the debate on Chronic Alcoholism will take place on Dec. 4th and 18th. Members are invited to show specimens of morbid changes attributable to alcohol in organs of (1) digestive, (2) cireulatory, (3) genito- urinary systems on Dec. 4th, and of (4) nervous, (5) respira- tory, and (6) cutaneous systems on Dec. 18th. Intimation of intention to exhibit specimens and of microscopes required should be given to Dr. Coupland before Dec. Ist. The dis- cussion on both evenings will be general, the division of the exhibition of specimens being merely for convenience.

MEDICAL SOCIETY OF LONDON.

Adjourned discussion on Dr. Howard's

per on “A New Method of Raising the Epiglottis. %

AN ordinary meeting of this Society was held on November 19th, Sir William Mac Cormac, President, in the chair.

Dr. BENJAMIN HOWARD introduced the subject by giving

a brief epitome of his communication, an abstract of which we published on page 819.

r. BRYANT said that a considerable time ago, when Dr. Howard was pursuing his investigations on this subject, he was struck with the thoroughness and conscientiousness of his work, and was therefore quite prepared for the valuable nature of the information contained in his paper. The facts he had brought forward were supported by demonstrations upon the dead body, and the impossibility of raising the epiglottis by means of traction on the tongue was clear] proved. He felt quite prepared to endorse Dr. Howard's remarks, or most of them. Mr. Clover had demonstrated that tilting up the chin facilitated respiration; but it must not y Meer that traction on the tongue was also often of use, and this was explained by Dr. Howard’s own experiments, which show that pulling on the ne displaced it from the posterior pharyn wall. It could not be thought that in every case of embarrassed respiration the epiglottis was at fault, for as often as not it was due to the simple falling backwards of the tongue. The practice of tilting the head backwards was often resorted to, and he thought that this heretofore empirical proceed- ing was explained by Dr. Howard’s paper. Though the position of the ae | suggested was very suitable for a certain class of operative cases, he himself preferred the usual position—in such an operation, for example, as the removal of an upper jaw—chiefly because he was more used to it; but younger surgeons who had not yet got into bad habits would doubtless profit by the suggestion.

Mr. KNOWSLEY THORNTON, who occupied the chair in the absence of the President when the paper was read, said that two letters had been written to him bearing on the subject, ——s that the work of the authors in this direction had been overlooked. One was from Dr. Foulis of Edinburgh, a passage from whose communica- tion he read, to the effect that so long as ten years he had himself used a special form of instrument, a “‘ glosso- tilt,” by means of which he pressed forwards the base of the tongue and the hyoid bone in apnoea, and he had sent a diagram to illustrate the mode of employing the instru- ment. Mr. Thornton thought it a misfortune that Dr. Howard should have made no allusion to Dr. Foulis’s paper in the Edinburgh Medical Journal; that paper, however, did not embrace all the ground covered by Dr. Howard, so that the latter had a perfect right to speak of his way as a ‘“‘new method.” Two great points in Dr. Howard’s were the creation of a free post-oral air-way, which Dr. Foulis did not seem to have recognised, and the fact that his method could be applied in the absence of all instruments, which was a great improvement.

Dr. E. A. SANSOM said the procedure now described had recommended itself to him many years ago as by far the best position in which to place the subject when about to perform artificial respiration. He thought Dr. Howard’s way gave the best and most direct entrance for air into the lungs in cases of chloroform narcosis. He had early satis- fied himself that mere pulling on the tip of the tongue was not by any means the best method ; it was certainly inferior to pushing down the base of the tongue with the finger or spatula. One particular point he felt required emphasis: the question was less how to get air into the lungs than how to get the air saturated with chloroform out, and, as Dr. Howard’s method afforded the best inlet for air, it would, of course, also allow the best outlet. He did not desire to be understood as endorsing Dr. Howard's whole system of treatment for the drowned, for he thought it involved risk of serious violence to the thorax and its cor tents.

Mr. T. PICKERING Pick said there was no explanation in Dr. Howard’s paper of the combined action of the sterno- hyoid and sterno-thyroid muscles ; their action a to him to be antagonistic and opposite to the muscles of the supra-epiglottic region.

Dr. ~ V. Hewitt doubted if the conclusions arrived at by Dr. Howard from the examination of dead bodies were correctly applicable to the living subject, in whom the con- ditions were necessarily very different. Under an anesthetic, and especially under ether, a condition of spasm of the muscles of the mouth and tongue was present which often rendered it almost impossible to get the mouth open. Under these circumstances it was impossible to adopt the method without danger, for neither by extension of the head nor by tilting forward the jaw was one able to admit air to the lungs. With a patient under nitrous oxide there was often a considerable amount of respiratory embarrassment towards

THE LANCET,)

WEST LONDON MEDICO-CHIRURGICAL SOCIETY.

(Nov. 24, 1888. 1021

the conclusion of the administration, dependent upon a sudden elevation of the larynx to the epiglottis, in common with other clonic movements over the body. In this case Dr. Howard’s method would be quite inadequate to restore respiration. He asked whether this method was considered applicable to all cases of apnoea.

r. LENNOX BROWNE said that it was important to bear in mind some of the physiological and clinical facts con- nected with this matter. He was surprised to find that Dr. Howard closed the mouth when the head was extended. He quoted the case of a patient under the care of Dr. Wolfenden who could only swallow when placed on a couch, sucking his food through a tube from a basin placed on the ground. Dr. Buxton, in his paper on Intubation, had remarked that in feeding children the head should he held back. When the head was much extended, elevation of the epiglottis would often occur to sych an extent that Ed view of the larynx could be obtained, and this suppo Dr. Howard’s contention.

Mr. MARMADUKE SHEILD asked whether, in carrying out the experiments on drawing out the tongue, the traction was exercised only on the tip. He showed that if the tip were drawn upon the anterior fibres of the genio-hyoglossi were put on the stretch, which prevented further movement; whereas if the tongue were seized further back and rotated the epiglottis could certainly be raised. He mentioned that in cases in which the anterior part of the tongue was removed there was a great tendency on the part of the remainder to fall back with the epiglottis over the larynx, a contingency which had led many surgeons to pass a liga- ture through the stump_beforehand.

Dr. STOKER observed that the remarks of the last speaker would only apply when patients were in the ordinary reclining ~~ but not when placed in the position advo- cated by Dr. Howard.

Mr. SHEILD replied that he had observed the same ten- dency even when the head was extended.

Sir WILLIAM MaAcCormac thought that if the base of the tongue were pressed forward the epiglottis was got out of the way ; but the question was, which was the best way of effecting this. He referred to a case in which, after con- siderable difficulty, respiration had been restored by placing the head in extreme extension, but as soon as the head was allowed to resume the usual position, respiration ceased, to recur only on being once more extended.

Dr. HOWARD, in reply, stated that Mr. Clover was about the second person to whom he communicated his views on the subject, and Mr. Clover had expressed himself as very much surprised that for years he had been in the habit of propping up the chin without knowing how or why relief was afforded. He confessed that he had totally overlooked the paper of Dr. Foulis, and nothing was further from his idea than to rob anyone of the credit which was duetothem. He objected, however, to the employment of any instrument, and said that Dr. Foulis’s plan necessitated the mouth being forced open before the ‘* glosso-tilt ” could be += a proceeding which was often difficult and brutal. Dr. Foulis

by lowering the jaw, but this facilitated the descent of the epiglottis; besides, the object of his instrument could as well attained by the finger of the surgeon. He had joe age J avoided the subject of artificial respiration, con- ning his attention strictly to the subject of the po. The antagonism of the sterno-hyoid and _ sterno-thyroid muscles was indispensable to the effect which it was desired to obtain. He claimed that the condition of impending apnoea was very comparable to that found in the cadaver, and he complained that medical men heretofore, in speaking of and writing on apnea, had shown an utter want of nice discrimination as regarded the exact stage alluded to, which was a point of very great importance.

WEST LONDON MEDICO-CHIRURGICAL SOCIETY.

Presidential Address.—Suppurative Peritonitis. THE first ordinary meeting of the present session was held on Oct. 5th, Dr. Travers, President, in the chair. In his presidential address, Dr. TRAVERS reviewed the condition of the profession on his entering it as a pupil in 1853, contrasting it with the present. e spoke of the

advan which the student and practitioner of to-day mo ene andl their predecessors both from a professional and

social point of view. He showed that the qualified aspirant now started not only better equip to carry out fairl efficiently his daily work, but, beyond this, wasendowed wi an amount of knowledge of scientific medicine that urged him to pursue his student life throughout his entire career. Hence the necessity of such societies as the one he was now presiding over, the proof of such necessity being their increasing number, fulness of attendance, and enhanced vitality. He instanced how valuable the branch meetings of the British Medical Association had been to its provincial Fellows in breaking down the old ideas of exclusiveness and petty jealousy, and replacing them by free interchanges of professional opinions and social courtesies, thus abso- lutely raising the status of the —— not only in the eyes of its own members, but in that of the world at large.

e felt confident that, when thirty years hence a future yw should repeat his task, he would have to acknow- edge that this Society had contributed its quota in pro- ducing the marked progress he must at such a time have to rejoice over.

Dr. THUDICHUM then read a paper on Uremia and its — with the alkaloids and extractive acids of the

rine.

Dr. ABRAHAM showed microscopical specimens of morbid conditions of the skin.

Mr. Percy DUNN showed some interesting pathological specimens.

At the meeting held on Nov. 2nd, Dr. Travers, President, in the chair,

Mr. KEETLEY described two cases of Suppurative Peri- tonitis treated by laparotomy, iodoform gauze, and capillary — drainage, the patients being both school girls, aged eleven, treated in the West London Hospital in May, 1887, and August, 1888, respectively. Case 1: Lilian S—. Sudden attack of vomiting, severe abdominal pain, &e. Always in good health before. The vomiting and pain con- tinued, and on the third day became much worse. There was no constipation. Both defecation and micturition were painful, and there was a tendency to diarrhea. On the seventh day the lower half of the abdomen was swollen, hard, and evidently contained fluid. rature 100°. On the ninth day the case came under Mr. Keetley’s care, and he 1 the abd The intestines were not distended, and were matted together. By we | them several collections of pus were exposed and evacuated, and the hot boracic douche was used copiously, with drain and daily syphon douche. The day after the operation she was decided! better; no pain; no vomiting. That night the pain mor cnc | suddenly ; at 5 A.M. diarrhoea commenced, and at 9 A.M. she died. Post-mortem: Intestines extensively adherent, especially in and near the right side of the pelvis, where a small mass of adherent intestine encl both the vermiform appendix and the right uterine appendages. A concretion in the appendix was so easily squeezed through its wall that probably a perforation existed, and had given rise to the peritonitis.—Case 2: Jessie K——, also aged eleven, was exhibited to the members present. She had had scarlatina nine months before illness. Says she has had a “ big belly” ever since. No albumen in urine now. A fortnight before admission she was kicked in the right loin and in front of the abdomen. Thesame evening vomiting, severe pain, and delirium set in. On admission there was abdominal pain, the epigastric and hypochon- driac regions were swollen, tender, and fluctuating, and there was slight subcutaneous edema. Laparotomy was performed, pus evacuated, and a warm douche given (1 in 5000 sublimate solution). A large rubber drainage tube was passed into Douglas’s pouch. Two large pieces of iodoform gauze were introduced, one into Douglas’s pouch, the other into the right iliac region; and when brought out of the wound were carried round the right flank, so as to hang out- side sufficiently as to act as syphon drains. Moist iodoform gauze under-dressing was used, and a wood-wool pad placed over all. The temperature fell from 102° to 99°, and recovery was steady, except that a curious kind of delirium _re- sembling mania came on and persisted for some days. The patient did better when boiled water was substituted for medicated douches. She was discharged quite well, with the wound perfectly healed, two months after admission. Three other cases of laparotomy for suppurative peritonitis were briefly mentioned.—Dr. DrEwitT asked Mr. Keetley whether in any of his cases there was complete constipation

as well as vomiting, as he seen two children in whom

1022 Tue LANcET,)

SOCIETY OF MEDICAL OFFICERS OF HEALTH.

[Nov. 24, 1888.

rulent peritonitis simulated intestinal obstruction.— Br. ALDERSON had aspirated a case, drawing off a pint aad a half and later half a pint of pus. Afterwards he opened with a Syme’s knife. The patient got well, but now has a hernia in the situation of the wound.— Dr. Lewers said that disease of the uterine append- ages should be borne in mind among the -e ble causes of acute general peritonitis in women. He had examined the pelvic organs in 100 bodies at the London Hospital, taken at random from all aay of the hospital, and found the Fallopian tubes dilated in seventeen cases; of these, five were cases of pyosalpinx. In one of them death was certainly due to oy of the tubes, causing general peritenitis, and in another also the pyosalpinx was very probably the cause of death. In cases of acute general peritonitis in women, therefore, Dr. Lewers thought that a eareful pelvic examination should be made, and, if evidence pointing to disease of the uterine appendages was found, the proper treatment would certainly abdominal section, washing eut and draining the peritoneal cavity.— Mr. BALLANCE mentioned a 7 who had a blow en the abdomen, followed by pain in the right iliac fossa, treated with opium Xc., followed by general peritonitis and death on the sixth day. The post-mortem revealed general sup- purative peritonitis. In cases of repeated pain in the tight iliac region, perhaps during twelve months, he

vocated operation during an interval to avoid general peritonitis at some time occurring during an attack.—

r. KEETLEY briefly replied. He thought that the surgeon should be called in to such cases from the first, not necessarily with a view to operation, but with a view to early consultation and decision as to under what con- tingencies or at what time operation should be done.

Clinical cases were shown by Dr. Drewitt, Mr. Keetley, and Mr. Ballance; microscopical specimens by Dr. Abraham ; and pathological specimens by Dr. Crombie, Mr. Dunn, and Mr. floyd.

Mr. LAKE showed a typhoid chart of the case recently related by him in THE LANCET.

SOCIETY OF MEDICAL OFFICERS OF HEALTH.

A MEETING of this Society was held on Friday, Nov. 16th, Dr. W. H. Corfield, President.

A paper was read by Dr. FRANCIS BOND, entitled ‘‘ The Government Act in its Sanitary Aspects,” of which the fol- lowing is an abstract :—The author observed that, para- doxical as it might appear to say so, the Local Government Act, although it does not contain a single clause which embodies any new provision of a sanitary character, and ve little, indeed, that touches on sanitary administration at all. will probably prove—so far, at any rate, as rural and small urban districts are concerned—one of the most important contributions to sanitary legislation which have been made by Parliament since the Public Health Bill of 1872. The justification of this assertion is to be found in the possibilities that lie hidden in the very modest provisions of the 17th, 18th, and 19th sections of the Act, which, when theirimport- ance is recognised, as it cannot fail to be, contain the germ of a whole gospel of ——- improvement. These clauses empower a county council to appoint one or more medical officers of health, and contain provisions by which the council will be enabled, if this power is wisely used, to lay the foundation in each county for a sanitary organisation of a far more satisfactory character than that which exists at present. It was just forty-one years since the officership of health was first created by Parliament in a very tentative manner as a provision of the Towns Improvement Clauses Act, and the history of sanitary progress since that date conclusively showed that every step which had been taken by local authorities in the way of action to —— the public health had been taken by the advice, and in most cases as a result, of the pressure exerted upon them by medical officers of health. If, there- fore, the influence of these officials had been so beneficial in the case of the smaller local authorities, who will shortly be transformed into district councils, what reason was there to suppose that it would not be equally useful when brought to bear upon the more important county authorities whom the Act had created? In dealing with the question what are the functions of a county council in the discharge of which the advice and assistance of a medical officer of health

are likely to be of any use, Dr. Bond pointed out that, though the sanitary duties of county councils as indicated in the Act are very vague, there are three which are distinctly con- templated in it, for the satisfactory discharge of which the exercise of ‘he power conferred on these bodies to appoint one cr more medical ofliccrs of health was essential. The first is the promotion of efficient and economical adminis- tration by the combination of all the local areas of a county under the smallest number of officers of health who may be required to properly watch over the health of the whole district. This could only be done gradually by takin advantage of opportunities of combination as they occurred. The second duty of county councils is one in which the advice of a medical officer of health is essential in the exercise of those powers of supervision over the sanitary action of district councils which the Act had imposed on them. The third is the utilisation, for local as well as for imperial purposes, of the large mass of statistical and other informa- tion which county councils will have at their disposal in the reports on the sanitary state of their district which will be sent to them. If to these duties which the Act has already imposed on county councils be added those which have been foreshadowed by the Bill of last session as about shortly to be added to them, as well as those which public opinion is prepared in addition to entrust to them in connexion with the protection of public health, there will be ample justification for their availing themselves without any unreasonable delay of the — in regard to the appointment of medical officers of

ealth which the Act has put into their hands. Dr. Bond had no hesitation in saying that if the sum expended in this department of public administration in every county were expended more judiciously than it is, far more efficient results could be obtained at little or no additional cost to the ratepayers. In conclusion, he pointed out that the Act failed to provide any remedy for the grievance of which medical officers of health had so long and so bitterly complained, in the want of security of their tenure of office, which placed them at the mercy of any cabal which personal malignity might raise against them, and which had led in numerous cases, some of which were cited, to the infliction of the gravest injustice on these officials, for which they had not the least redress. Until the medical officer of health had the same protection in the honest discharge of his duties which Poor-law medical officers have, the interests of the public must infallibly suffer. It was earnestly to be hoped that this defect might be remedied in the Bill to be introduced next session as a supplement to the Local Government Act.

ROYAL ACADEMY OF MEDICINE IN IRELAND.

Aneurysms.—Ectopia Ventriculi.—Cystitis.

AT a meeting of the Pathological Section on Nov. 2nd, Dr. WALTER SMITH exhibited the viscera of a man, aged fifty-four years, admitted into Sir P. Dun’s Hospital on May 18th, 1888. He was a porter by occupation, and enjoyed good health, although not temperate. Thirty-four years ago he had a venereal sore on the penis, and a sup- purating bubo. About eight years ago he was in Jervis- street Hospital for a tumour in the left popliteal space, which was treated by ‘“‘ pressure” and cured. On April 10th, 1888, he suddenly became faint and tly distressed in his breathing, and after five months’ suffering died. The prominent symptoms were pain across the upper part of the chest, over the left side, and down the arm; also over the upper dorsal spines, which were tender. He was much troubled with dyspnea, but the laryngeal symptoms were never marked, and he could swallow without difficulty. A considerable bulging of the three upper ribs on the left side existed, dull on percussion, and exhibiting pulsation syn- chronous with that of the heart. There was neither cardiac nor aneurysmal murmur. The pulse in the left arm could searcely be felt, and was delayed. A few days before his death he was seized with rigors, retching, and intense pain in the back and left side. The temperature rose to 103°4°. He ually became cyanotic, and died on Sept. 25th. At the necropsy the left pleura was found to be adherent; right pleura almost completely free. There were numerous subpleural hemorrhages over the base of the right lung. Occupying the upper part of the thorax was a large ovoid tumour, measuring five by four inches; this proved to be an

Tue LANCET,]

REVIEWS AND NOTICES OF BOOKS.

(Nov. 24, 1888. 1023

aneurysmal sac, arising about one inch above the semi- lunar valves of the aorta, and almost completely filled with a firm laminated clot. The bodies of the second, third, fourth, and fifth dorsal vertebrae were eroded, and, the pos- terior wall of the sac of the aneurysm being deficient, the blood clot lay in contact with the vertebrae. The in- nominate and left carotid arteries were not involved; the left subclavian artery was flattened by the tumour. The esophagus was incorporated with the wall of the aneurysm, and the left vagus nerve was flattened into a tape-like band. The aorta was slightly atheromatous above and below the aneurysm. An old infarction was found in the right lung. The left popliteal artery and vein were fused together into a firm mass, and the lumen of the artery was completely occluded by a dense organised thrombus.— Dr. M‘KEE remarked that no very advanced degree of atheromatous or sclerotic change was necessarily associated with aneurysm; and this was supported by the fact that aneurysm was not a disease of late, but rather of middle life. A point in this case which struck him as rather anomalous was the smallness of the heart. An as question was whether aneurysms occurring in persons wit a syphilitic history were attributable to immediate syphilitic change or to the effects of the syphilis on the constitution generally. The latter hypothesis was, he thought, sufficient to explain the occurrence of the aneurysm.—Dr. Foor said this case bore out three important points laid down by the late Dr. Stokes. One was the non-increase of the tumour, by which it was distinguished from other tumours which were of a rapidly growing nature. The second point, to which Dr. Smith had drawn attention, was the absence of murmur. The third point, to which Dr. M‘Kee had called attention, was that in thoracic aneurysm the heart was not necessarily hypertrophid unless the aneurysm was sufficiently near to the region of the aorta to make the valves incompetent. The case reminded him (Dr. Foot) of one which he had at the Meath Hospital many years ago.—Dr. SMITH said an important clinical point was the variability of the signs and symptoms of aneurysm, and another feature was the curious relief that was sometimes temporarily given by a local abstraction of blood in the case of aneurysmal tumours, and which would not have the same effect at allin an organic tumour. The infrequency of murmur was one of the points of difference between thoracic and abdominal aneurysms.

Dr. C. B. BALL communicated a case of Ectopia Ventri- culi. A tumour of the size of a was removed from the umbilicus of a child aged two months. The surface was red and moist, and microscopical examination showed that it consisted of glands identical with the pyloric glands of the stomach. The centre of the tumour was com of bloodvessels and muscular tissue. Only six of the re- corded cases exhibited gastric glands, most of the others having a mucous membrane similar to that of the intestines.

Sir WILLIAM STOKES communicated a case of Cystitis after the removal of papillomatous tumours from the female bladder. The tumours had been removed some three years before the death of the patient by Mr. Grei Smith, and the post-mortem appearances were those o

of the bladder.—Dr. M‘KEE had examined a portion

of the bladder in this case, and found clusters of epithelial cells in the muscular layers, which could not have existed there if the tumour had been simply a benign one.—Mr. WHEELER said he had had four cases of papillomatous wths under his care from time to time.—Professor

ENNETT said the question here was the same as that raised in the case of the late Emperor of Germany—-namely, whether it was sible that a papillomatous tumour, which was proved by microscopic examination to be benign, could pass into an epithelioma. They did not usually find cases of papilloma of the anus and other localities turning into carcinoma.—Dr. Foot ob- served that the kidneys of the patient, which had been sent round, appeared to him to be quite sufficient to account for her death, when taken together with the prolonged irritation, pain, and loss of rest that accompanied the cystitis.—Mr. Story said he had no difficulty in believing in the development of a benign tumour into a malignant one.—Sir WILLIAM STOKES, in reply, said that Professor Bennett would find it to be laid down by several authorities that papillomatous disease of the bladder had a special tendency to run into carcinoma, and he thought, from what had been laid down by Mr. Hutchinson and Sir James Paget, that there was a pre-cancerous stage in a vast number of cases of cancer.

MEDICO-PSYCHOLOGICAL ASSOCIATION.

THE quarterly meeting of the above Association was held at Bethlem Royal Hospital on Nov. 16th, Dr. Clouston, of Edinburgh, President, in the chair.

The Council reported that, owing to the resignation of Dr. Rayner through ill health, it had been arranged that Dr. + should act as temporary secretary till the annual meeting.

Dr. ft Percy SMITH exhibited a specimen of Pachy- meningitis of the Spinal Cord, in which the effusion was on = of the mater. ollowed on the nature and pathology of pachymeningitis,

Dr PLAXTON, of

Kennoway, a yop is Fifeshire, where he was able to see ) e boarding-out system for chronic lunatics,

by which the Scotch manage to care for a very large number

ot their weak-minded and harmless lunatics without form-

ing large collections of such cases asis seen in England. A

discussion followed in which the Scotch members took an

active part.

The members dined together in the evening.

Hebicos and Hotices of Books.

siecguenting ; tts Principles and Practice. By H.C. Woop, M.D., LL.D., Professor of Materia Medica and Thera- utics and Clinical Professor of Diseases of the Nervous ystem in the University of Pennsylvania. Seventh Edition. Pp. 908. London: Smith, Elderand Co. 1888. Ir would be incorrect to describe this as a new book, and yet the title, scope, and arrangement have been so largely altered that it possesses much of the interest belonging to a new publication. In the previous edition the book was called ‘*‘ A Treatise on Therapeutics, comprising Materia Medica and Toxicology.” The present issue bears on its title-page the following descriptive paragraph : ‘‘ A work on medical agencies, drugs, and poisons, with especial refer- ence to the relations between physiology and clinical medicine.” The introduction of the term ‘medical agencies” means a good deal. It is the keynote of the tone of mind in which the author has approached his task, and its position on the title-page before ‘‘ drugs and poisons” is maintained in the body of the book. This the author justifies by referring to the increasing interest taken by the medical profession in the various remedial measures which are distinct from the administration of drugs. Although some of these remedial measures were dealt with in preceding editions, they occupied a very subordinate position, and were treated rather cursorily. Space has now been devoted to somewhat detailed con- sideration of massage, metallo-therapy, the feeding of the sick, and the dietetic and general treatment of various constitutional diatheses. Hitherto these subjects have been deemed worthy of special manuals; by incorporating them in his book upon Therapeutics Dr. Wood endeavours to bring them under the notice of a wider section of the profession. The remarks upon Feeding in Sickness are based upon the assumption that pecuniary considerations are of secondary importance ; the costliness of many of the dietaries would prevent their common employment among the poorer classes. In the treatment of fevers the author recommends the habitual use of foods which have been partially digested artificially, and he regards pancreatin as the most efficient digestive agent. This section contains a number of valuable directions for the preparation of food

| Negro. Dr. Plaxton is convinced that the so-called ‘ey. meningitis is due to wee o of brain, followed by a compensatory hemorrhage, and is not in any way inflam- matory.

Dr. HAcK TUKE read a paper on a Recent Visit to

1024 THe LANcET,)

REVIEWS AND NOTICES OF BOOKS.

_ [Nov. 24, 1888.

for the sick, details being so fully described that there should be no difficulty in following them. Rectal alimenta- tion, which is mostly rather glossed over in text-books, is also explained with commendable precision, the import- ance of the employment of opium in aiding the retention being duly insisted upon. Metallo-therapy is dealt with extremely cautiously. The impression derived is that the author has felt the necessity of mentioning its reputed results, while not pledging himself too fully to any criticism. He blandly remarks that “it is certain that, at least in this country,” the phenomena ‘‘ are exceptional.” Perhaps the difficulty he experiences in explaining the phenomena may account for this caution; one theory he denounces as amounting to ‘‘ nothing more than words.” With regard to the treatment of corpulence, due prominence is given to the so-called Banting system, upon which so much criticism has been expended ; but the Ebstein method is preferred by the author, and he also quotes approvingly Oertel’s recom- mendations for diminishing cardiac strain by systematic violent muscular exercise in mountain climbing. This section is, of necessity perhaps, rather disappointing ; its chief novelty, apart from an occasional quaintness of diction, lies in the incorporation of these subjects in this volume.

Turning now to the second part of the book, which deals with drugs, the author claims some credit for his arrange- ment of material. The order in which to deal with the endless array of drugs has always proved rather a stumbling- block ; many authors in despair have followed the alpha- betical lead of the Pharmacopeia, and thus reduced their work to the level of a dictionary. Professor Wood has attempted a semi-physiological method, and has com- menced with a broad division of systemic remedies from extraneous remedies, the latter including antacids, anthelmintics, digestants (sic), absorbents, and disinfec- tants. Systemic remedies are considered as general and local. The general remedies, which are more important, he further divides into orders, which are termed ‘ nervines,” “‘cardiants,” and ‘‘ nutriants.” Of these, the first two are well arranged and form part of a natural classification; the inelegant term ‘‘somnifacient” is here employed to unite narcotics and hypnotics. The nutriants form an extremely artificial order, including astringents, tonics, alteratives, anti- periodics and antipyretics. The drugs grouped under local remedies also rest upon a very uncertain physiological basis, ranging from stomachics and emetics to diluents and protectives. To criticise this arrangement is rather a thankless task, since it amounts to criticism of the lack of uniformity of view concerning the most important action of the various medicinal agents. The physiological order is clearly that by which details will be most readily grasped by the student, and, although it does not appear to be per- fect, the present arrangement is certainly preferable to that of the last edition.

Of the newer remedies Professor Wood speaks pro- visionally. As arule, he is content to offer a summary of the experience of others, but occasionally he gives his own results. Lanolin is discussed upon physiological grounds, and thus practically disposed of. Ichthyol, in spite of the extravagant praises of Unna, Kiesner, and many German dermatologists and surgeons, is dealt with in somewhat sceptical terms. The author has used it in sprains with ‘‘ apparently some relief,” but he feels, after a review of the evidence, ‘if one-half that has been said of it be true, it is a remedy of extraordinary power and

value,” which is a sufiiciently qualified statement. Bhe efficacy of strophanthus he considers proved by clinical observations, but he draws attention to the difference in the strengths of the preparations in the market. Of adonidine and sparteine he offers nothing beyond the

he regards as “barbarous.” He speaks highly of the value of sulphuretted hydrogen, when given by the mouth, in cases of phthisis, chronic bronchitis, and other chronic pulmonary affections, but his remarks in this connexion form a statement of belief in the natural sulphur waters rather than a criticism of the Bergeon treatment. Among other innovations will be found notices of the hypnotics, paraldehyde, urethan, and hypnone, of kawa, of salol, bethol, and antifebrin. The remarks on many of the articles men- tioned in previous editions have been brought up to date. Professor Wood has done his work thoroughly and con- scientiously. He evidently distrusts-many of the state- ments which he has felt it his duty to quote, but he has been careful not to mislead by the personal adoption of every unverified novelty. In fact, he seems frequently to have laboured under the idea that ‘‘the only safe con- clusion on the evidence is that the evidence does not warrant any conclusion” (p. 414).

Diseases of the Skin; their Description, Pathology, Di is, and Treatment. By H. RADCLIFFE CROCKER, M.D. Lond., F.R.C.P., Physician to the Department for Diseases of the Skin in University College a, Physician to the East London Hospital for Children, Examiner in Medieine at the Apothecaries’ Hall of London. With 76 Illustrations. Pp. 746. London: H. K. Lewis, 1888.

THE multiplication of special services for diseases of the

skin in many great centres of industry and university towns,

the increase in the number of those who give particular attention to these affections, and the keen investigations that have been carried out in recent years, have resulted in the publication of an ever-increasing mass of litera- ture, and in the issue of many special treatises of more or less value. Drs. McCall Anderson and Jamieson in Scotland have recently issued works, but in England it is some time since any work of the first importance has made its appearance, and this latter circumstance has led many, especially those resident abroad, to conclude that the study of dermatology is somewhat sluggish in this country. As a matter of fact, it has never been so spirited, and the number of thoroughly qualified workers has never been so great. Dr. Crocker’s book, gracefully dedicated to the memory of his former teacher the late Dr. Tilbury Fox, will be good evidence of the first-rate work that is going on here and of the excellent calibre of the workers. The author has set himself to produce a book which should within a reasonable and convenient compass give a succinct account of our present knowledge of dermatology, and which would serve alike as a work of ready reference to the genera} practitioner and a suitable text-book for the student. He has succeeded admirably, and his efforts cannot fail to be most favourably received. Dr. Crocker shows himself to be thoroughly aw courané with dermatological literature, and the results of all important modern research are carefully digested and embodied in the volume, which is also valuable as a record of the author’s own extensive experience acquired in twelve years’ practice in University College Hospital and elsewhere. The matter is well proportioned, very accurate,

and concise, and we cordially congratulate the author on a work which will worthily represent the present school of British dermatology. There is a useful appendix of formule: supplementary to remedies suggested in the text.

ABERDEEN MeEpico-CHIRURGICAL Society. — At the annual meeting of this Society, held on Nov. 15th, the following office-bearers were Dr. James W. F. Smith-Shand. Vice-President: Dr. Robert John Garden. Secretary: Dr. George M. Edmonds. Recording Secretary: Dr. Alexander Macgregor. Treasurer: Dr. John Gordon. Librarian: Dr. Thomas Best Gibson. Council: Drs. James Rodger, James M‘Kenzie Booth, Henry Jackson, Angus Fraser, and T. Best Gibson.

reports of others. The Bergeon treatment of phthisis

Tus LaNcer,)

INTRODUCTORY ADDRESSES AT THE DUBLIN HOSPITALS. [Nov. 24, 1888. 1025

Abstracts INTRODUCTORY ADDRESSES

DELIVERED AT TIk

DUBLIN HOSPITALS

AT THE

Opening of the Session 1688-89.

ADELAIDE HOSPITAL.

Mr. BARTON, in the course of his address, said the proper aim and object which everyone who was entering the pro- fession of medicine should keep steadily before him, and the true spirit which should animate every member of the profession as long as he lived, were to endeavour to obtain wide, accurate, and practical knowledge of the profession, and to try to keep up with the advancing tide of knowledge and abreast of the improvements and discoveries which were almost daily being made. A real and difficult course of study lay before the student of medicine before he could be styled «‘Dr.”; and at present the profession maintained in Dublin a standard of general culture, as well as of professional train- ing, which he believed he could truly say was second to none im any part of the world. The student could never safely confine his work to any one branch of the profession. He might think of becoming a specialist in one single branch hereafter, but he must be no specialist before he passed his final examination. He would never, indeed, be a proper specialist unless he had laid the foundation in a broad and really sound knowledge of all the various sciences which bore upon medicine asa whole. The range of subjects in which the student was requi to was increasing ‘every year, and what sufficed very well twenty years ago would be at present quite insufficient, and an intimate acquaintance with subjects not even named then was now required merely to pass. The lecturer then referred to the various examinations medical students would be required ‘to pass, and pointed out the best means of preparing for each examination, advising them to be persevering and to

y a great deal of attention to the practical portion of their studies. When they thought it very hard that a man had been stopped at his examination, he begged them to remember the responsibility that rested upon those who were charged with the duty of giving them a qualification ‘to practise. If they pursued their profession in the spirit of serving one another as God had served them, they would gain independence and an honourable name, which they all highly prized and jealously guarded. Even, if being called upon to attend Queen or Emperor, they should be assailed = a combination of all the German professors in the world, there was no necessity for outery, no need to seek the pro- tection of the law of libel, or to write the events of the sick room to be read by the whole world; they might, with perfect calmness, leave their deeds, not their words, to speak for them, confident of the justice of their brethren.

CHILDREN’S HOSPITAL, UPPER TEMPLE-STREET.

Mr. BAXTER, in the inaugural address, gave a résumé of ‘the literature of children’s diseases, and entered into an extended description of the peculiarities they presented as differing from diseases in the adult. He described the proper methods of arriving at a diagnosis in the special ailments peculiar to children, and explained some of the systems of treatment which long experience at the hospital had shown him to prove most successful in combating the most formidable diseases of childhood in their early and advanced stages. The lecturer dwelt largely on the advantages of a children’s hospital as a school # clinical

study, and pointed out how necessary an accurate know- ledge of these diseases was to the young practitioner, the special facilities for acquiring which knowledge were avail- able in that hospital.

MEATH HOSPITAL.

Dr. Moore said that on that day they inaugurated the 138th session of the Meath Hospital as a school of clinical teaching in medicine and surgery. He had purposely laid stress upon the date of the opening of the present session because it told them that effect had at last been given to a long talked of and desirable reform. From time immemorial in the history of the hospital the first Monday in November in each year had been set apart for the formal opening by an inaugural address of the winter session, which in name always commenced on the first day of October. The wisdom of such an arrangement, common to the Meath Hospital with all the kindred institutions and medical scheols in Dublin, was certainly questionable ; and he was gratified to think that to this far-famed hospital, around which so many cherished memories clung, belonged the credit of beginning a new order of things, in accordance with which the full teaching machinery of the institution was put in motion at the very commencement of the session, and not, as had hitherto happened, a month or five weeks later. Since their last ‘‘ opening day” several events had occurred which were destined to find a place in the annals of the Meath Hospital. Of these, the first was the resignation of one of the most esteemed and respected members of the medical staff, Janes Henry Wharton, the second in seniori of the surgeons of the hospital, a man whom they could i afford to lose. The vacancy on the surgical staff caused by the resignation of Mr. Wharton had been filled by the pg tee of Sir William Stokes, who, after an absence of twenty years, had returned to the hospital where he first won his spurs as a skilful operator and able surgeon, and where to all time the honoured name of Stokes would be a name to conjure by. A third notable event of the past year was the payment to the hospital authorities of the Bury bequest, about which they had all heard so much during the last nine or ten years. Unfortunately, in consequence of the depreciation in value of land in Ireland within recent times, this munificent bequest was seriously diminished in amount. Nevertheless, it was most accept- able, and would permanently endow several additional beds in the hospital wards. During the official year 1886-87 a munificent uest of £4500 was paid over to the Standing Committee by the Crown, acting as represen- tative ot the late Mr. John Barber. In the summer of 1887 the building of a memorial wing to perpetuate Mr. Barber's name in connexion with the hospital was completed within a year, and many of his audience were present a few days since at the formal opening of the new wing by his Excellency the Marquis of Londonderry. ~

ST. VINCENT’S HOSPITAL. Dr. McHveu, in his address, referred principally to the question of the amalgamation scheme between the three Dublin medical schools. It had, he remarked, the almost unanimous support of members of the profession not directly interested. As regarded the night students who were affected by the measure, and who had his sympathies in their struggle for existence, he would ask them to remember that Trinity College and the Royal University had already decided against them. The danger which they had to fear was that the College of Surgeons would fall into line with the universities and refuse to admit them to their diplomas. This would be a death-blow to them, as the alternative of going to Edinburgh would not then exist, the conus there accepting such certificates only as were recognised by the Irish College. The Carmichael and Ledwich directors had expressly stipulated that the night men who had = their studies should be enabled to complete them. The existing night students would therefore establish themselves in the School of the College of Surgeons, and would have thus obtained practical r ition instead of tolerance simply as heretofore. He had no doubt that by legitimate agitation they would retain permanently the hold which they would thus as a consequence of amalgamation have acquired upon the College. There was no foundation, in his opinion, for the charge of sectarianism made against the promoters

1026 THe LANcET,)

NEW INVENTIONS.

(Nov. 24, 1888.

of the measure. He stated this creheiety as one who had been conversant with the negotiations and steps which had led to its attainment. Having referred to other matters closely affecting the Dublin School of Medicine, the lecturer concluded an interesting address.

Hew Inventions.

THE IMPROVED SIMPLEX ENEMA APPARATUS.

SomE years ago' I described a new form of enema appa- ratus, which Messrs. Arnold and Sons, of West Smithfield, made at my suggestion. It was called ‘The Simplex,” and I ventured to claim for it that it possessed many advan- tages over those in ordinary use, and this assertion has been amply justified by the test of experience. The essential differences between it and any other enema apparatus were: Ist, there was no packing on the piston; 2ndly, there was no indiarubber, being made of metal ; and 3rdly, it could be used with one hand without fatigue. It consisted of two cylinders, sliding without friction one within the other. The inner one, which acted as a piston, was raised by a spiral spring and depressed by the hand. Around the top of the outer cylinder was a circular chamber, into which a little water was forced at each downward stroke. This water acted the part of the packing in an ordinary piston, none other being required. This was, of course, a great gain, as the packing of a piston which is not constantly used and oiled is sure to become dry, loose, and useless, especially in hot climates, and it is no easy matter to pack

a piston well and smoothly, especially on an emergency. Dispensing with indiarubber was another gain, as this is sure to spoil by the mere lapse of time, and, besides, com- pressing an indiarubber ball, even when in good order, is very fatiguing to the hand. Now, ‘‘The Simplex” was always ready for use, no matter how long it had been put aside. The only fault I ever heard found with it is that the parts being all loosely connected, and not in any way fitted together, they are apt to be lost or mis- laid. This drawback having been pointed out to Messrs. Arnold, they have remedied it in a very ingenious manner in “The Improved Simplex” enema apparatus they have just produced. The inner cylinder, which was long enough to act both as piston and piston rod, has been very much shortened. The piston rod is now separate, and is of much smaller diameter. It is made to pass through an opening in the upper part of a dome-shaped cover, which is screwed on the top of the outer cylinder. This dome-shaped cover forms the water chamber, which, as already described, enables us to dispense with any packing round the piston.

“2 See THE LANCET, Aug, 17th, 1872,

.

‘On the lower end of the piston rod is a projecting collar, which prevents it either falling out or being shot out by the action of the spring. It is only by unscrewing the dome cover that the apparatus can be taken to pieces, and until that is done none of the parts can be disconnected from the others, thus obviating any chance of losing them. An exterior cylinder is added to form an air chamber, in order to render the jet continuous. Wishing to make the apparatus as nearly perfect as possible, Messrs. Arnold have fitted the cannula with a simple but efficient water joint, so that it. can be placed at any required angle with the outlet pipe without impeding the flow of the fluid. Two small flat cylinders of equal diameter, closed at one end, have their open ends fitted together by means of a water-tight collar, thus forming a closed cylindrical box, the two parts of which can be turned round on each other, having a common axis. The cannula is fixed to an opening in the periphery of one part and the outlet pipe to an opening in the peri- phery of the other, so that these two openings, being in different planes, are never obstructed, no matter how they may be turned as regards each other, and the flow of the liquid is consequently unimpeded. W. L. Sueparp, M.R.C.S. Willis-road, N.W., Sept. 11th, 1888.

A NEW BED-REST.

THE bed-rest of which illustrations are annexed appears to possess the desiderata of extreme portability when not in use, and great capacity of expansion (Fig. 1) when im

Fia. 1.

The bed-rest opened.

service. The wands which form the back support are sufficiently thin to yield to a moderate extent to the weight of the body, offering, however, sufficient resistance to avoid an uneasy posture. When folded (Fig. 2) it occupies so

2.

The bed-rest closed.

small a space as almost to escape observation, and the notches on the back frame allow of its being arranged at- any convenient angle. The bed-rest is wade vy: Mr.,Salt, . Corporation-street, Birmingham.

j << ty > = | Nk SSS ——

Tar Lancet,)

[Nowr24; 1888.)

THE LANCET.

LONDON: SATURDAY, NOVEMBER 24, 1888.

THE concluding volume of the Encyclopedia Britannica, which has just been issued, contains one article which will be certain to attract attention in the medical world; yet, unlike the rest of the contents of this great literary achievement, it neither reflects the prevailing knowledge of the day nor treats of the matter in hand with impartiality. We say this advisedly, although we know well that the author of this remarkable essay lays claim to having viewed his subject without any bias, and doubtless prides himself on having shaken off the trammels of orthodox belief and pursued a perfectly independent and original course. We refer to the article on ** Vaccination,” the novelty of which is somewhat discounted by the publica- tion by its author last year of his brochure on “ Vaccinal Syphilis.” Those who _read that contribution of a dis- tinguished pathologist to the history of cow-pox will not be startled at the line of argument adopted in the Encyclopedia, although they may well be amazed at the inclusion of such teaching in a work which should be authoritative and should serve as a standard of reference for a generation. Dr. CREIGHTON is well known as a most painstaking student of pathological literature, but, with all deference, we submit that he has no claim to be considered an authority upon practical medicine. We give him every credit for the labour and skill that he has devoted to the preparation of his article, but we cannot allow that his theoretical views, based upon the study of the history of vaccination, can have any weight in opposition to the experience of the profession during the greater part of a century. In order, however, to justify our preceding remarks, we will briefly survey the chief points of the article referred to, which the author frankly admits runs counter to the prevailing views.

_ In the first place, Dr. CREIGHTON sets aside, as “arbitrary and untenable,” the doctrine of variole vaccine propounded by JENNER and adopted by nearly all his followers. Vaccinia, he says, has no relation whatever with variola. It is only in the vesicular stage that any similarity obtains between the two exanthems. The natural course of cow- pox is to proceed to ulceration, the ulcer having indurated edges and resembling far more the primary syphilitic sore than the variolous pustule. He points out that it was owing to the disastrous results of vaccinating with primary lymph that JENNER abandoned his own supply ; and that, had it not been for WOODVILLE’s more favourable and less severe results, the practice of vaccination might have been nipped in the bud. But, as experience showed, the farther removed from the cow the slighter were the local and con- stitutionai effects ; although, by failing to adhere to the rule of taking the lymph early from the vesicle, there would bea risk of inducing in the vaccinated the graver results of primary vaccination. Calf lymph is analogous. to humanised

in-that the calf is only employed as the vaceinifer, and the

esulte-of -vaecination from’ it’ are not to be compared with

those which occur when the transfer is made direct from » the cow. As to the attempts to replenish the steck of lymph by ‘‘equine virus” or by “ variolating the cow,” he sarcastically condemns both practices as equally irrational - and theoretical, and declares that in the latter instance it is — small-pox that is transmitted by vaccination. Of course, having determinedly rejected the doctrine of relationship between cow-pox and small-pox, it is easy to maintain the inutility, or rather the error, of attempting to obtain» vaccine by variolating the cow; but Dr. CREIGHTON fails to mention the face that the results of protective inoculation in other diseases by means of ‘‘ attenuated virus” may well be urged in support of the practice introduced by Mr. BADCOCK.

Having rejected any relationship between vaccinia and variola, it is interesting to note that the author considers . cow-pox to be an infectious disease, arising out of a ‘ecommon physiological or constitutional eruption” on the teat of milch cows, and acquiring its special characters by ’ the persistent irritation to which it is subjected at the hands of the milker! We fear that the explanation given of the nature of cow-pox will hardly satisfy the reason of mast pathologists. Dr. CREIGHTON seems unable to sever him- self from a train of thought regarding the origin of specifie disease which is, to say the least, fanciful; and hence it is that, by detaching cow-pox from small-pox, he has had te invent a hypothesis for the pathogeny of the former which, to our thinking, is as ‘“‘arbitrary and untenable” as in his opinion is the Jennerian doctrine. Hence we are less sur- prised at his further development of the subject, when, in speaking of the risks of vaccination, he includes erysipelas, jaundice, skin eruptions, vaccinal ulcers, and vaccinal syphilis—not, as the unsophisticated might regard them, as evidence of foreign contamination of the vaecinal lymph, but as incidents which are part and parcel of: cow-pox itself, a reversion to the type of manifestations produced by primary inoculation from the cow. Nothing in’ all the history of pathology can be more grotesque and, in the light of present knowledge of the nature of syphilis,’ more absurd than his contention that infantile syphilis is largely due to the vaccine virus; not that syphilis is trans mitted with the vaccine, but that what we call ‘‘vaccinal: syphilis” is simply vaccinia of a severe type!

It is needless to add that, in the subsequent paragraphs upon the practice of vaccination as a prophylactic for small- pox, the writer minimises the teachings of experience on this head. He has a theory about small-pox, too, which he must harmonise with facts, and he thinks he sees in the: epidemic outbursts and the periods of freedom from epi-: demics that occur evidence in support of his view! that. small-pox is a foreign contagious skin disease, imported into Europe from Afriea, and destized, like the plague and typhus, to ultimately disappear from Europe, uninfluenced by vaccination. We maintain that he has given no satis- factory proof of the correctness of the views which he puts forward so dogmatically. We believe, too, that JENNER’s fame and the value of his discovery will not be affected one iota by the arguments whieh are advanced in this article, and which, appearing in the pages of a standard work, may be thought to be the last words of modern seienee. on»

the subject ; whereas they may be more fittingly described.

1028 LANCET,)

‘OPERATIVE SURGERY AT PASS EXAMINATIONS.

[Nov. 24, 1888.

as pathological tr dentalism. In his memorable report on the ‘‘ History and Practice of Vaccination” (1857), Sir (then Mr.) Joun Simon alludes to the fact that, with few exceptions, the medical profession soon became unanimous on the subject; and his remarks on one class of objectors seem to have some application in this instance. He says: ‘‘ Also, to a very small extent, allowance must be made for personal eccentricities, which (in respect of vaccination as of every other subject) have ever caused solitary voices to be raised against the common convictions of mankind. This influence can searcely cease to operate. Occasionally, no doubt, till the end of time there will be found some lover of paradox ready, in mere wantonness of authorship, to choose his text from SQUIRRELL or ROWLEY and to write dispraise of JENNER, as CARDAN wrote his encomium on NERO.”

In 1881-82 the Visitors appointed by the General Medical Council issued a report on the Final Examinations of the numerous licensing bodies in Great Britain and Ireland, and one of the most important suggestions therein was that the English and Scotch corporations should follow the lead of the Royal College of Surgeons in Ireland, and institute an examination in Operative Surgery. Such a recom- mendation, made by such authorities in medical education as Mr. TEALE and Professors GAIRDNER and STOKES, was bound to attract notice, and although no official action was at once taken it could not be altogether ignored. In their reference to the pass examination of the Royal College of Surgeons of England, they state that ‘‘ it would be desirable that steps should be taken to test the candidates by actual operation on the dead body, as it is only by this method that their knowledge can be satisfactorily tested in that important branch of surgery.” With regard to the Irish College of Surgeons, they consider that the final examina- tion affords valuable experience on the method of testing candidates in operative surgery, and they were ‘ most favourably impressed by the excellent and efficient way in which every candidate was tested in operative surgery, and that without any undue expenditure of time or trouble.” At the meeting of the Council of the Royal College of Surgeons of England on the 8th inst., a committee was appointed, on the motion of Mr. MACNAMARA, seconded by Mr. PEMBERTON, to consider and report whether it be desirable, and, if so, practicable, that candidates be examined in operative surgery on the dead body. There can be no question that, if practicable, such a proceeding is most desirable, for every practitioner has to perform minor operations on his patients, an1 may be called on at any moment to perform major operations. Amputations or ligature of large vessels after accidents, tracheotomy, or operations for acute strangulated hernia may be impera- tively required when there is no opportunity for calling in an experienced operating surgeon, and even in so-called minor operations grave risks may be incurred if the surgeon has not an eflicient knowledge of, and skill in, practical surgery. The question of the general adoption of operative surgery as a test subject in our final surgical examinations therefore resolves itself into one of the feasibility of such an examination being carried out by the licensing bodies granting surgical diplomas. If it be adopted in

England as well as in Ireland, before a candidate be allowed to receive a diploma which qualifies him to practise surgery, we presume that a similar course will be speedily followed in Scotland, or we shall have a further perpetuation of unequal examination tests in the three divisions of the kingdom, and this would be most deplorable on every ground. So far as practicability is concerned, we are at once met by an enormous difficulty—viz., the expenditure of time and trouble and in the adequate supply of subjects which this new departure would involve. At the Irish examination ‘‘ thirty-three candidates were examined in an hour and a half, and three subjects sufficed; but probably double the number might have been efficiently examined without an additional subject.” This statement by the Visitors gives the only official data with which we are acquainted on which a judgment as to the practicability of such an examination can be formed. At the Con- joint Examining Board in England last year more than 850 candidates presented themselves in surgery at the final examination; so that, adopting the same ratio, forty additional hours, or ten additional examination days, would be required if the number of candidates and examiners were in the same proportion in England and in Ireland. The enormous amount of time now consumed in England by examinations deters many of our best and highest surgeons and physicians from acting on the Conjoint Board ; and additional labour, such as this change would necessarily involve, would inevitably lower the personal character of the Examining Board. The most active teachers and the most hard-worked consultants in such a centre as London could not spare the time or take the trouble which such a duty must involve. If operative surgery be introduced, some other part of the examination must be given up or abridged, the present style of examina- tion altered, or an increase in the examining staff must be made. Tosuch an increase the serious objection of a further inequality in the judicial powers of the examiners, now frequently and often justly urged, at once arises. In Ireland, candidates are taken in turn on the written, oral, clinical, or operative parts of the surgical examination, and may be rejected in any of these divisions, allowing an examinee to reckon all that he has passed, but such a subdivision would hardly find favour in England. Operations them- selves must vary as tests, but the personal equation of the examiners should be reduced to as nearly a constant quantity as possible. The supply of subjects for examina- tions in operative surgery is a still further difficulty. Even allowing that sixty-six men can be examined efli- ciently on three subjects, which, despite the above-quoted dictum of the Visitors of the General Medical Council, we shall venture to question, nearly forty additional subjects must be forthcoming for the examinations of the Conjoint Board in England alone. It is only in recent years, in con- sequence of Professor HUMPHRY’s action, by which licensed teachers are able to begin the winter session with subjects remaining over from the summer, that a sufficient supply has been obtained for students to perform their dissections, and in the case of advanced students only is it possible to go through a systematic course of operations on the dead body. Itis very questionable if this supply can be increased, and if forty subjects are required by the Conjoint Board,

ARTHRECTOMY.

(Nov. 24, 1888. 1029

to say nothing of the other licensing bodies in London, in addition to the forty now used annually for examinations, it will be impossible for the teachers of anatomy to ade- quately instruct their students, and give them due oppor- tunities for the practice of the ordinary dissections. A very large number of additional subjects, too, would be impera- tively demanded for teaching systematic operative surgery, if this subject were made compulsory on everyone before practising as a surgeon. In Scotland the number of can- didates presenting themselves annually at the universities and the licensing corporations is even greater than in England, and the difficulties as to examiners and to sub- jects—already much less numerous in proportion to students than.in England—will be proportionally more serious, and almost, if not absolutely, impossible to overcome. The existing examinations in operative surgery for the Fellow- ship of the Royal College of Surgeons and for the B.S. and M.S. degrees are on a different footing, for here presumably each candidate expects to become a hospital surgeon, and facility for dexterity in operating is an essen- tial for such an appointment; and yet, although there is only a limited number of candidates, the tests are some- times unequal and unsatisfactory, and fairly grounded com- plaints in this branch of the examination are not infrequent.

The scheme works pretty well in Ireland, because candi- dates are proportionally few and subjects numerous. In England it seems to us almost impracticable ; its introduction would altogether alter the character of the present examina- tion. In Scotland we think that it could not possibly be efficiently carried out; and general practitioners should be licensed on similar examinations, so far as practicable, in the three divisions of the kingdom.

We venture to put forward these objections because they must be met by the Committee before any report in favour of the proposal is presented to the Council; and we shall await with much curiosity the decision of a board of practical surgeons and examiners, composed of the President and Vice-Presidents of the Royal College of Surgeons, Sir W. Mac Cormac, Messrs. BRYANT, MACNAMARA, and BERKELEY HILL, who will be able to point out how, if it be possible, these difficulties can be overcome.

—

THE papers recently contributed to two of the Medical Societies of London by Mr. HERBERT PAGE and Mr. EDMUND OWEN will no doubt direct the attention of surgeons to the claims and value of the operation now called arthrectomy. The substitution of excision of joints for amputation in cases of articular disease was in obedience to the great principle of conservative surgery that healthy parts should not be sacrificed while removing diseased parts. It marked a great advance in surgical practice, but its beneficial results have only been fully obtained since the introduction of aseptic surgery. In the newer operation of arthrectomy this principle is still more fully carried out. In the old excision a joint was sacrificed and a limb was saved; in the new arthrectomy the diseased parts only of a joint are removed, and all the healthy parts are pre- served. It is an advance upon excision as originally and

usually performed in two ways: healthy parts are not interfered with, and diseased parts are most carefully

fixed on a neat removal of the joint ends of bones, and the obtaining of proper apposition of the sawn surfaces and the result was that outlying portions of disease in the soft parts were not unfrequently left behind, while by the unnecessary removal of healthy portions of bone much greater deformity than necessary was produced. These facts were too apparent not to force themselves upon the attention of surgeons, and hence it happens that many have been concurrently working in the same direction, and have arrived at the same goal—the substitution of arthree- tomy for excision. There are two or three questions which are now ripe for discussion. The first is this: Given a case of destructive joint disease in which only parts of the joint are affected, is the complete removal of those parts only likely to be followed by a speedy recurrence of the disease in those left behind? The older surgeons would have answered in the affirmative; they held that when one con- dyle of the femur was the seat of tubercular disease the other condyle was certainly specially predisposed to that disease. Arthrectomy largely rests upon the belief that the disease is a locally infective one, and that by removal of the diseased foci the healthy parts are protected and preserved intact, and that its chief element of success is the complete removal of every portion of diseased structure. As a corollary to this comes the question whether there is any practical advantage in leaving behind healthy portions of a joint. The evidence already accumulated is conclusive on this point. Deformity is lessened, more useful limbs are secured, and in some cases a movable joint is obtained where under other circumstances a synostosis would have resulted. How often movement can be preserved, and the value of a slight range of movement in such a joint as the knee, are questions on which different views are held by surgeons, and which can only be decided by further experience. Much will depend upon the extent to which the disease has implicated the joint, and upon how much of it needs removing; much will also depend upon the success with which an aseptic wound-course can be secured.

The most important qnestion in relation to arthréctomy | is as to the time at which it should or may be undertaken. The facts that removal of diseased structures protects the healthy from attack, that the operative procedures them- selves can be rendered practically free from danger, and that in its early stages the morbid process is limited to small portions of a joint, logically lead to the conclusion that by early operation the integrity of a joint may be very largely preserved. In such a matter there is room for distinct difference of opinion, and it will require time to establish the best line of practice. It should act as a restraint upon those ardent operators who would resort to arthrectomy in the earliest period of tubercular arthritis to remember that undetected morbid tissues may escape a very careful search, and that a septic arthritis is a much worse affection than tubercular disease. On the other hand, those more cautious surgeons who would prefer to wait for any operation until suppuration evidences the severity of the morbid process, must often have to stand by inactive while further healthy tissue is being destroyed. The difficulty is to fix upon some happy mean which will give the patient the maximum of good with the

searched fur and removed. In excision attention was often

minimum of ill. One thing at any rate is clear: no surgeon

1030° THe LANCET,]

THE BOWMAN LECTURE.

[Nov. 24, 1888.

should attempt an arthrectomy for early tubercular disease until he can practically guarantee that the joint shall not become septic, nor until he has made himself familiar with the details of the management of joint operations. The surgeon who opens a large joint to search for and remove a limited patch of tubercular disease assumes a grave responsibility, but so does he who stands idly by while a limited patch of tubercle slowly but steadily spreads and involves in destruction more and more of a joint. The truth would seem to be that arthrectomy rightly employed is a great advance in the therapeutics of diseased and injured joints, but that with the advance surgeons have to sustain a greater responsibility in the care of such cases.

To sum up the whole matter we may say that—-l. Every

excision of a joint should be an arthrectomy—i.e., a com- plete removal, as far as possible, of all diseased and injured tissues, with a minimum interference with healthy parts. 2. By a successful arthrectomy healthy parts of a joint may be preserved from disease, and thereby deformity may be prevented and function maintained. 3. Where rest and other palliative measures carefully carried out fail to secure a distinct improvement in a tubercular joint, early arthrec- tomy is advisable, as delay exposes the patient to the risk of general tubercular infection, to wider joint destruc- tion, and to a more extensive operation at some future time. The name arthrectomy is objected to by Dr. NEALE, who writes to us suggesting the use of the term ‘‘ arthrotomy.” But this term is already rightly employed to denote the operation of cutting into a joint, and great confusion would result from the application of the word to another surgical process. Arthrectomy denotes the cutting away of a joint, and, as such, is applicable to the old excision or the more modern procedure of erasion, to which we think it will be convenient to restrict the use of the word.

AN able and interesting lecture in commemoration of the services rendered to biological science in general, and to ophthalmic medicine and surgery. in particular, by Sir WILLIAM BowMAn, was delivered before the Ophthalmo- logical Society of Great Britain at their last meeting by Dr. Swanzy of Dublin. The subject’ he undertook to illustrate was the value of eye symptoms in the localisation of cerebral disease. The great advances that have been made during the last few years in the determination of the functions of special areas of the brain by the united efforts of the anatomist, physiologist, and pathologist, and the knowledge that in many instances well-marked disease of the eye accompanies cerebral disease, naturally lead the ophthalmic surgeon to reciprocate the benefits thus obtained by supplying those facts which he has learnt from experience indicate disease of special regions of the brain. Unfortu- nately, as Dr. SWANzyY remarked, in many of the cases that fall under the care of the ophthalmic surgeon no necropsy is made, whilst in many of those that are made the record obtained is so meagre and imperfect that little or no con- clusions can be drawn from them. He therefore maintains that the interests of science as well as.the reputation of the physician are best served by entrusting the. examination. of the brain in all cases of this kind to a skilled :patholo.,|

gist and microscopist, instead of undertaking it himself.

The principal affections to which Dr. SWANzyY called the’ attention of the Society were, in the first instance, those of conjugate lateral deviation of the eyes: in these cases, when’ they are due to paralysis, the eyes look towards the side on. which the lesion is sitnated ; when they are owing to spasm, the eyes look from the seat of lesion. Conjugate deviation of the eyes may resuit from lesion of the cortex, of the internal capsule, or of the pons, in the latter case affecting the superior olivary body or special nucleus for the associated action of the sixth and third nerves, and in each case there are special symptoms which enable a diagnosis to be made with tolerable certainty in regard to the precise seat of the lesion. On the other hand, loss of the power of convergence probably indicates lesion of the posterior quadrigeminal bodies. Amongst the other paralyses of the cranial nerves supplying the motor apparatus of the eye which afford a clue to the seat of the cerebral lesion, is ptosis, which, if monolateral, may be a focal lesion of the cortex of the opposite side or of the pons on the same side, or, if double, may be due to some disease of the corpora quadrigemina, or, by forming a factor of a crossed paralysis may, serve to localise a lesion in the crus cerebri. Complete paralysis of all the branches of the third nerve, without any other paralysis, almost always indicates basal lesion. Paralysis of the fourth nerve is sometimes basal, but may indicate disease in the crus extending to the valve of Vieussens, especially if asso- ciated with more or less complete paralysis of the third. Paralysis of the sixth nerve, if accompanied with hemiplegia of the opposite side of the body, indicates a lesion in the pons, usually a hemorrhage, on the side corresponding to the affected nerve. After referring to lagophthalmos, and to nystagmus, and to the localising value of paralysis of the fifth nerve, Dr. SWANZY discussed the condition of the pupils in intra-cerebral disease, which he thinks is rarely of much value in regional diagnosis; and then proceeded to consider the localising symptoms derivable from the visual apparatus, such as partial and complete hemianopsia and impairment or loss of colour vision or hemiachromatopsia. These sym- ptoms, in accordance with their greater or less intensity and with their transitory or persistent nature, appear to afford much aid in the localisation of cerebral disease, especially when they are considered by a physician who is well versed in the general symptoms accompanying such affections. Dr. Swanzy adduced some remarkable cases of ‘*mind blindness,” as it has been termed. The affection is occa- sionally seen in the advanced cases of general paralysis, the patient being unable to recognise the streets of a city in which he has long been resident, and may not know his own door, or, stranger still, the face of his own wife, though recognition is immediate through the voice and the hearing. Some interesting information was also given in respect to the condition knowna as alexia, or loss of the power of understanding printed or written speech symbols, which is probably associated with lesion of the angular gyrus of the. left hemisphere; and to that of dyslexia, in which there is. marked indisposition to.read. Dr. SWANZy is in accord with most physicians as. te absence of value as a localising character: of . optic: neuritis; that symptom occurs in. most cases. of: intra-cerebral, tumour, irrespective of the: seat of the growth. «Finally, he paid .a, fitting tribute: of praise to. the high professional, character and great.

THE LANCET,)

THE GENERAL MEDICAL: COUNCIL.

(Nov. 24, 1888. 1031

scientific attainments of Sir WILLIAM BOWMAN, who, we may cordially hope, will long live to be the object of similar and well-deserved honours.

THOSE who have any business to bring before the Medical Council should remember that it meets next Tuesday, at 2o’clock. The meeting is in accordance with a standing order of the Council, agreed to in November last, to the effect that the General Medical Council shall meet every year for general business on the fourth Tuesday in May, and, if necessary, again on the fourth Tuesday in November. This is without detriment to the power of the President, as provided in Section 9 of the Medical Act of 1858, to call the Council together at other times, either at his own discretion or on the written requisition of eight members of the Council. Speaking generally, the May meeting is that for the discharge of the general business of the Council, and the November one for such subjects as affect the purity and accu- racy of the Register. Removals from the Register by the occurrenceof death can of course be dealt with by the Registrar on information supplied to him from the Registrars of Births and Deaths. Registrars are specially charged with this duty, and receive a fee for such information. They are required to send a special certificate of the death of every registered medical man, whether in practice or retired at the time of death. The greatest number of deaths reported in any late year is 711, Unfortunately, almost every year there are cases in which names have to be removed from the Register on the ground of crime or seriously unprofessional conduct. And not the least grave, as it is certainly one of the most painful, duties of the Council at its November meetings is to deal judicially with cases of medical men convicted of crime by courts of law or charged with conduct condemned by the Medical Council.

One of the most important duties of the Council next week will be to discuss the reports of the Inspectors of Examinations appointed by the Council under the Act of 1886. The profession will remember that three gentlemen of great ability (DAvip W. FINLAY, B.A., M.D., Inspector in Medicine; EpwArD H. BENNETT, A.B., M.D., Inspector in Surgery; A. H. F. Barsour, M.A., M.D., Inspector in Midwifery) were appointed to visit and report on all the Final Examinations for the qualifying diplomas and degrees of the various medical authorities in each division of the kingdom. These reports were not quite ready for considera- tion in May. The Council will discuss them at a greater advantage now, as they have had more time to consider them, and especially as they can be read in connexion with the answers of the various bodies to the criticisms of the Inspectors. It is not a slight feat on the part of the Inspectors in one year to have done so much work. We shall not anticipate the nature of their criticisms or of the ‘conclusions with reference to our examination system’ to which they may lead. It is never easy to anticipaté the range of discussion or the duration of the séssion of the Medical Council, but we see little reason for their sitting more than a few days.”

SuRGEON-Masor JouNn Incr, M.D.,.is a candidate for aseat on the Kent County Council. for the representation of the Dartford No. 2 Division.

Annotations,

“Ne quid nimis.”

THE FRIENDSHIPS OF PHYSICIANS.

A SPECIMEN of what literature might gain from an effective volume on this subject is afforded by the recent essay of Moleschott on Donders, in which one eminent Dutch physio- logist and consultant describes his recollections of another in some respects more eminent still. It is, it seems, an aeademic law in Holland that every occupant of a chair, no matter how vigorous and competent, becomes emeritus on completing his seventieth year. This has just been the fate of the distinguished ophthalmic physician of Utrecht, and the Professor of Physiology in Rome seizes the occasion to review the career now academically closed, and to set forth in a series of striking incidents its relations with others which have been elosed also, or are still running their course. It was, he says, in the house of their common scientific parent Mulder, the great pioneer of physiological chemistry, that he and Donders came together and formed the attachment that has so deeply affected both of them. This was in 1844, when the discoveries of Schleiden and Schwann were but six years old, when organic morpho- logy was beginning to be transformed, and when only in 1842 had appeared the great work of Henle, which impressed on the revolution they had effected the character of a comprehensive and fruitful reformation, Schwann and Henle, in examining the chemical nature of the tissues, knew no means beyond acetic acid and water; and Moleschott recalls the sceptical look of Henle when, in 1844, he told him that Mulder and Donders had determined on making their histological attack with potash and sulphuric acid ! Mulder got Harting to work for him in the vegetable and Donders in the animal kingdom, and, thanks to a method at once consecutive and sound, they reached a stage when, according to Moleschott, the historian of histology will show how the principles that induced Virchow and others to classify the tissues and their com- ponents in great part proceeded from the micro-chemical researches of Donders and Mulder. It was the eye that had most attraction for Donders, however ; and Moleschott well remembers the modestly furnished room in which his friend, in 1845, prosecuted his researches into the rotation of the organ. A red ribbon was his sole apparatus, and this he caused to hang perpendicularly to the wall, and then he ob- served the position of the images behind it, to ascertain if the eye simply follows the movements of the head, or if it effects a rotation independently of these movements. At our modest supper, continues Moleschott, he would sit with the lamp in front, and by means of a bit of perforated card- board he followed the shadows of corpuscles situated on the surface or in the interior of the eye, and in this way he examined the so-called endoptic phenomena on which he wrote the memoir which still remains the best on the sub- ject; a ribbon, a small mirror, a playing card, a micro- scope—his laboratory in those days contained nothing more—verifying the saying of Dove and Pfliiger that exact experiment does not depend on costly and complicated apparatus. His work on the accommodation and refrac- tion of the eye—translated into six European languages— procured him the friendship of Albert von Griife, into whose arms, says Moleschott, he was literally thrown by von Jiiger in London in 1851. Von Griife called himself Donders’ pupil, while Donders boasted of von Griife as his master—‘‘masters both of them, Donders in the science, von Griife in the art, both complementing each other and indissoluble.” Von Griife’ afterwards wrote to his Utrecht friend: “I want to see-you spon and by every possible means. Not a, day passes but I have something to tell you and to talk

1032 THE LANceErT,]

SMALL-POX PREVENTION IN THE PORT OF LONDON.

(Nov. 24, 1888.

to you of. This remains the true measure of the intimacy that unites us—that we are gathering, silently, the one for the other, those flowerets which each day is scattering on our paths. Yet sometimes we must express ourselves. Let us try and not fail to reciprocate in our short lives.” One great achievement of Donders’ life was the foundation of the Ophthalmic Hospital at Utrecht, subscribed for by the Dutch people, organised by Donders himself, and made by him the medium of such luminous and memorable in- struction that there is not now a moderate-sized town in Holland which does not possess a sound and skilled oculist. With all this special proficiency Donders has never ceased to command the whole field of physiology—in all its ramifi- cations of physics, chemistry,and microscopy. Form, matter, force, as abstractions and as entities, have been, says Mole- schott, ever present to him. The circulation of the blood he has studied in connexion with the nervous influence that governs it. He has examined not only the laws of refraction which the accommodation of the eye (as explained by Cramer) completes, but he has measured even the velocity with which we see and hear, with which we judge, select, and will. He has analysed the sucking of the child at the breast and the speech of the adult. Many things which belong to Donders in science have the currency of sound coin, although they have not the Hall mark of his name. Embryology, accord- ing to Moleschott, is perhaps the only biological subject on which he has not left his impress. In private life the glimpses his biographer gives us of him are delightful: his skill in music, on the violin particularly, being such as to charm many a maestro; while his extraordinary command of living languages (to say nothing of his sound Latinity, which he attributes with gratitude to the fathers at Box- meer) brings his conversational riches within reach of Englishman, Frenchman, and German with equal facility. And all this is set forth to us by a fellow-student and friend of Donders. How much more may we not one day expect from such a pupil as his successor in the Ophthalmic Hospital at Utrecht.

SMALL-POX PREVENTION IN THE PORT OF : LONDON.

Dr. COLLINGRIDGE’S report on the Port of London for the first half of the present year shows, as usual, that vigilance is maintained in the great water-way of the Thames to prevent the importation of disease, and to secure improvement in the sanitary state of shipping. The amount of infectious disease which may at any time have to be controlled in the port is by no means inconsiderable; and the difficulties that may have to be met in this respect lie not so much in the number of beds in hospital that may be required for this purpose, as in contriving that the several diseases shall be so isolated that persons admitted for one disease shall run no risk of contracting another. It is known that some years ago the Port Sanitary Authority erected the first portion of an excellent isolation hospital just below Gravesend; but Dr. Collingridge very properly points out that this first instalment does not suffice for preventing all risk of the spread of infection from patient to patient, and that further means to secure the due separation of different diseases is needed. The occasion that has given rise to this difficulty has been the prospect of the reception of small- pox cases, an emergency which was on one occasion got over by the purchase of a separate hospital marquee; the per- manent hospital provision not admitting of the safe recep- tion of that disease at the same time that other diseases are under treatment. The occasion when the marquee was used is stated to have been during hot weather. This point is of importance in two respects. In the first place, success, as regards the sick, can hardly

be expected if marquees are used on the banks of the Thames during winter weather, and hence a tent hospital should be regarded as of limited use only. And, in the second place, the fact that the small-pox did not spread to the permanent buildings may also be due to the fact that in hot weather small-pox is a waning disease, and the infection is, in all probability, not in its most virulent stage. And it is this second consideration that would lead us to go beyond that which Dr. Collingridge’s recommendation may at first sight appear to mean. He advocates the erection of another ward for small-pox only; but he wisely couples this with the injunction that it should be at a ‘‘safe distance.” We feel convinced that that safe distance is not, at all seasons and under the varying stages of epidemicity, to be obtained on or imme- diately adjoining the present site; and we should advise that the port authority should be prepared either to seek a small-pox hospital site at a substantial distance from other buildings further down the river, or to build a hospital block on the lines recommended by the Royal Commission on Small-pox and Fever Hospitals. The matter is one which involves questions of some considerable importance, and it is one as to which the matured counsel of the port officer of health should be sought before a decision is arrived at. But atthe same time delay is to be avoided, for the need of the port of London in this respect is an obvious one.

ESTIMATION OF ALBUMEN IN URINE.

A QUICK and ready method for the determination of the actual quantity of albumen present in albuminous urine has always been desirable. Hitherto the methods in use—except that of Esbach, which is perhaps open to some objections— were either too complicated in their manipulation, or else took up more time than can be generally afforded by the majority of practitioners. H. Zahdr has, however, in the Zeitschrift fiir Physiologische Chemie (12, 484-494), devised a simple process which gives results accurate to the first place of decimals, and which can be carried out clinically. It depends upon the difference in the specific gravity or density brought about in the urine by the elimination of the albu- men. Such an estimation is termed a densimetric one. The method adopted is as follows. A preliminary examina- tion of the filtered urine is made in order to determine approximately the amount of dilute acetic acid necessary to precipitate all the albumen when boiled. This is easily ascer- tained by taking a small quantity of urine in a test tube, adding acetic acid, and boiling. The urine is then filtered from the coagulum, when the filtrate should yield no further precipitate with acetic acid and potassium ferrocyanide. A convenient quantity of the filtered urine, after the addition of the proper quantity of acetic acid, is then placed in a flask well fitted with a good cork. The flask with its con- tents is next placed for ten or fifteen minutes in a bath containing water constantly boiling. This brings about the precipitation of the albumen, which is then carefully filtered off into a flask fitted with a cork with a hole in it, through which the funnel is passed. It is advisable to cover the funnel during filtration with a glass plate. The density of the urine and the filtrate is then determined by means of a urinometer graduated to the fourth decimal place. Of course the temperature must be the same for both liquids. This precaution is easily taken by placing them in two glass cylinders immersed in a bath of water kept at a convenient temperature—e.g., 17°5° centigrade. The difference between the initial density and the final density is then multiplied by the factor 400, the product giving the number of grammes of albumen present in 100 cubic centimetres of the urine. The factor 400 is found to yield by experiment with a number of albuminous urines approximately accurate zesults,

THE LANCET,]

DEATH AFTER VACCINATION.

24, 1888. 1033

and depends upon the mean value of the specific gravity of albumen, which was found by the author to be 1°3747. It does not, however, appear to yield such good results with fluids containing albumen other than urine.

ALLEGED IMPROPER EXAMINATION.

It is to be hoped that the accumulating number of failures, on the part of women, to convict medical men of impro- prieties when in the discharge of ordinary professional duties will lead quickly to the discontinuance of that easy way of aspersing the good name of practitioners. Another case has ended in the complete discomfiture of the patient and vindication of the defendant—that of Alice Ann Adam, who brought an action for £50 against Mr. Robert James Cooke, practising at Chatham in partnership with Mr. Walter Buchanan, for an assault by an improper examination. The counsel for the plaintiff used that dogmatic statement against the defendant which is still the strange monopoly and privilege of lawyers, and than which nothing needs more to be brought under control. He said Mr. Cooke had committed a breach of professional etiquette, a breach of honour, and unquestionably an assault. Dr. Warren, afterwards called in, thought the examination deposed to by the witnesses for the plaintiff quite right, and said the girl was highly nervous. When the various evidence had percolated through the mind of the judge and jury they made short work of the case. The jury said at once that Mr. Cooke had made a perfectly justifiable examination, and the judge said costs would be allowed if applied for. Mr. Cooke generously declined costs, and the judge justly pronounced his conduct very handsome. It was an easy thought to make £50 out of a respected member of the profession, but it has met with merited failure. With all practicable precautions, it is next to impossible for medical men to avoid putting themselves into positions in which hysterical women can construct a theory of assault. But fortunately judges and juries are becoming skilled in estimating such cases. It is, however, very much to be desired that the friends of hysterical patients should think for them before sanctioning such ventures.

DEATH AFTER VACCINATION.

AN inquest was held by Dr. Danford Thomas last week concerning the deaths of two children which occurred in the St. Pancras Workhouse. These children had been vaccinated by the medical officer soon after admis- sion, and while they were in quarantine, eight days after the vaccination, they sickened with measles, from which disease they eventually died. The only medical opinion before the jury was that of the medical man who performed the operation, and he stated that he did not con- sider that vaccination had accelerated or had taken any part in causing the death of these children. The jury, however, came toa different conclusion, and returned a verdict that the deceased children died from stomatitis when suffering from measles, and that the death was accelerated by vaccina- tion, which took place eight days beforethe attack of measles; they added a rider that children in workhouses should not be vaccinated before or while in quarantine without the con- sent of the parents, when that can be obtained. We see no reason to differ from the medical opinion expressed, but the event is certainly unfortunate; it is undesirable that children not protected against smmall-pox should re- main in the workhouse or go out into the world in a con- dition of susceptibility to this disease, and this has no doubt led to the rule to vaccinate all children who have not previously been subjected to this operation. The matter is, however, one in which discretion might well be exercised;

and in times when small-pox is not prevalent, if the opera- tion can be deferred until the period of quarantine is over, it would tend to prevent even so rare an occurrence as that which has just taken place.

THE CARDIAC CHANGES IN CHRONIC BRIGHT’S DISEASE.

In a valuable paper (New York Medical Journal, Nov. 10th), Dr. Loomis discusses the well-worn topic of the relation between cardio-vascular changes and chronic Bright’s disease. He gives a table of forty cases, in which the details of the pathological lesions are summarised, and concludes that, as a rule, the more extensive the obliterating changes in the renal arterioles, the greater the degree of cardiac hypertrophy ; and that if such hypertrophy be absent the general nutritive conditions are faulty. He clearly describes the subsequent occurrence of cardiac degeneration and failure. He also, from a study of a large group of cases of chronic valvular disease, finds that in a not incon- siderable proportion the secondary renal disease is sufficiently pronounced to be considered as coming under the category of Bright’s disease. At the same time he holds no narrow view of the nature of Bright’s disease, regarding it ‘asa constitutional disease, in which the repair and waste in all the tissues of the body are imperfectly carried on; and in one way or another the kidney changes are expressive of other visceral and arterial changes, which, combined with the kidney lesion, make up the clinical and pathological history of the disease.”

SANITARY ADMINISTRATION AT BRIXHAM.

WE learn from a local journal that the town of Brixham, in Devonshire, is suffering heavily from scarlet fever, and the account published therein of a meeting of the local board gives some insight into the estimation in which public health administration is held in some districts. The popula- tion of Brixham at the last census was 5633, and the medical officer of health receives an annual stipend of £20 for the performance of his duties. A member of the board, com- menting on a remark that had been made that little or nothing had been done by the authorities to check the epidemic of scarlet fever now prevailing, made the amazing statement that he had heard that the medical officer of health had been engaged not to do his duty. It is due to the medical officer, however, to state that, in reply to a question by another member, he said ‘he had not failed to act in any way different to what duty laid down.” The outbreak is evidently a serious one, for we learn that during the fortnight preceding the meeting 150 persons had been attacked with scarlet fever and sixteen had died. It is doubtless some consolation to the local authority to know that the medical officer of health and his colleagues ‘‘ had known worse epidemics in the town than the present”; and further, that ‘the fever had been im- ported into the town, and nothing could be done to prevent its spread.” So much for sanitary administration in Brixham. We do not wish to take away the reputation of this salubrious spot, and we fully sympathise with one of the members of the local board, who is said to have stated : “Such matters had better not be reported; in Paignton last year, when typhoid and diphtheria were there, it was kept quiet.” Everyone will agree with him that Brixham ought not to be treated differently from Paignton. But, seriously, these circumstances create a grave scandal. We trust they will become known to the authorities at Whitehall, and that both Brixham and Paignton will be inspected and some steps taken to prevent the occurrence of these epidemics. If this should result, some good will have come from the publicity which has been given to the

=

1034 THE LANCET,]

CHILDREN’S LODGING-HOUSES.—FANCY MUTILATION.

(Nov. 24, 1888.

Brixham outbreak. When Dr. Davies examined this district on behalf of the Local Government Board in 1885, he stated that the sewers were inadequately ventilated, that ‘‘many houses were without any privy accommodation, there being no room about them ; hence excrement was stored up in the bedrooms until collected by the town scavengers.” It would be interesting to learn whether any improvement has taken place since that date.

OOPHORALGIA TREATED BY INTRA-UTERINE FARADISATION.

Dr. EVERARD of Mons contributes an interesting paper to La Clinique on the nature and treatment of oéphoralgia. In his experience the affection is usually accompanied by what are considered hysterical symptoms. The patients are asarule young girls, and they complain generally of violent and frequent headaches, buzzing in the ears, exagge- ration of the olfactory and gustatory senses, ocular troubles, loss of memory of words, anesthesia and hyperzsthesia of different parts of the body, capricious appetite, bad digestion, irregular bowels, and cough more or less frequent, for which no reason can be found on examination of the chest. The treatment hitherto has been chiefly sym- ptomatic, and has not been very successful. Dr. Everard has of late, however, employed Apostoli’s method. He uses a bichromate of potash faradisation apparatus, to which is connected an Apostoli’s bipolar rheophore con- taining the two currents, which are separated by a thin piece of gutta-percha. This sound is introduced either into the vaginal fornix or into the uterus itself. The coil is so arranged as to supply currents predomi- nating in tension or in quantity at will. Care must be taken to increase the strength very gradually, and to diminish it the moment the patient complains of pain. The greatest cleanliness is required, antiseptic injections being used before and after the sitting. Dr. Everard gives some cases where some half-dozen faradisations produced a great change for the better in hysterical patients with enlarged and tender ovaries.

CHILDREN’S LODGING-HOUSES.

Ir is satisfactory to learn that the useful proposal to open special lodging-houses for homeless London children, which was brought forward a few weeks ago by Mr. Barnardo, has not fallen to the ground. At a full meeting on Tuesday week, the project was again discussed, with a view to the establishment of two such houses. These are designed for the reception of girls and boys respectively. In them it 1s intended to provide, at the low cost of a penny, shelter for the night and some warm food for each child. The case must be necessitous indeed in which this very trifling charge cannot be met, and it seems almost impossible that any real impression can be made on the expenses of the undertaking without the adoption of a much higher tariff. We must not forget, however, that results by no means con- temptible have been attained by the distribution of penny, and even farthing, dinners to starving school children. It is not, therefore, hopeless that the penny fee may even do more than defray the cost of the food supplied in these lodging-houses. Should the nightly attendance be numerous, the contributions may do something to lessen the expense of rent, taxes, and lighting, and we may surely expect that public charity will not refuse to make up any small deficit which may remain. Other wants of this destitute class might also be considered by the many who will interest themselves in this good work. A common bath, if not too costly, would be an advantage. Advice, moral and religious, information as to work and how to obtain it, as to education, and the like, might also

be afforded to the inmates of these refuges, and would often be gladly received. In conclusion, we would express a hope that as far as possible overcrowding will be avoided. Inthe meantime all will agree that this well-intended project is worthy of a trial, and we therefore commend it heartily to public support.

CLINICAL CASES AT THE FELLOWSHIP EXAMINATION.

ArT the final examination for the Fellowship of the Royal College of Surgeons, which has been held during the past week, the clinical cases on the Wednesday were of much interest. These included amongst their number multiple sarcomata in’ the subcutaneous tissue, secondary to a pigmented mole removed some six months previously ; large sarcomatous tumour of buttock, (?) fibro-sarcoma of thigh; sarcoma of superior maxilla involving the skin and secondary growths in the cervical and submaxillary glands ; primary scirrhus of cervical glands on the right, and another on the left, side; epithelioma of superior maxilla; scirrhous tumours of breasts ; tumour in the floor of the mouth, with glandular enlargement; lymphadenoma of cervical glands; recurrent tumours of abdominal wall; three cases of advanced disease of the knee in patients the subject of tabes dorsalis ; ankylosis after fracture into elbow joint, with injury to ulnar nerve; ankylosis of elbow in a child; tertiary ulceration of shoulder; epilepsy of four years’ duration in a man who sustained a compound depressed fracture of the skull when a youth; tumour of abdomen; and dislocation of the shoulder in a man able to work as a fish porter, with great atrophy of the upper arm, the dislocation occurring when a child.

OXFORD UNIVERSITY AND THE LOCAL GOVERNMENT ACT.

A SCHEME which has been prepared jointly by the Town Council of Oxford and the Hebdomadal Council as to the relations of the city and the University under the new Local Government Act, has been submitted to Convocation, and, notwithstanding some strong protests to the effect that the University, by being always in a minority, would lose its influence and always be bound hand and foot in its pro- ceedings, it has been accepted by 62 votes to 27. The agreement involves a number of financial arrangements, and it provides that the new County Council shall consist of 36 members elected by the city wards, 12 by the University, and 12 co-opted by the 48 representatives thus elected.

FANCY MUTILATION.

EVIDENTLY the time has not yet come when Nature is to be regarded as a competent judge of what ought or ought not to appear in her own handiwork. Her products, no matter how normal their development, do not necessarily meet with man’s approval. If his eye for neatness in form is not satisfied, he still claims a right to prune or otherwise alter her creations to his liking. In particular is this true with regard to those animals in which he takes an interest. As a rule, he does not, at least in a civilised state, care to operate, save in cases of disease, on his own person, but here his agreement with natural modes of development ceases. He crops and docks his dogs, dishorns his cattle, blinds his pet birds, and otherwise exhibits a cruel originality in his self-assumed office of critic which on the whole does him little, if any, honour. A‘sthetically considered, this practice of mutilation is of at least doubtful value. Tastes may differ, but, as a rule, the majority of those who weigh their reas.ns for a decision will prefer to accept the work of Nature as it stands, rather than an artificial

Tue LANCET,)

REGISTRATION OF GIPSIES AND VAN DWELLERS.

(Nov. 24, 1888. 1035

modification of it. On the ground of fellow-feeling (for such undoubtedly exists between the lower creatures and the lord of the creation) mutilation is even less defensible. In the young animal which is usually the subject of such treatment, sensation may not, indeed, be so acute as in the older; but the fact remains that at any age pain is hard to bear, and, if unnecessary, is cruel. The natural conclusion from these considerations bids us therefore, both from the motive of humanity and of truth in taste, to desist from such mutilation, and to let Nature’s well-done work alone.

CASE OF TUMOUR OF THE STOMACH CAUSED BY HUMAN HAIR.

Dr. J. Bera, of Stockholm, records a case in the Nordiskt Medicinskt Arkiv of a married woman, twenty- six years of age, who for three years suffered from anemic and dyspeptic symptoms, accompanied by glairy vomiting. Two years before coming under observation a tumour began to form in the epigastric region, which had increased very rapidly during the last six months. On examination this tumour was found to be in the epigastric and left hypo- chondriac regions, between the middle and left nipple lines. It was as large as the hand, and was concave at its upper and convex at its lower border; it was movable, but could not be displaced downwards. The spleen was in its normal position. An exploratory laparotomy having been made, the tumour was found to be in the stomach, which was accordingly opened by an incision eight centimetres long and parallel to the greater curvature. The tumour thus exposed, being too large to remove in its entirety, was cut up and removed in fragments. It weighed 900 grammes, and was composed of hair tightly compressed. The wounds were sutured, union took place by first intention, and the patient left the hospital quite well at the end of three weeks. The patient herself did not remember to have eaten hair, but her mother said that she had that habit when quite a child. Dr. Berg has not been able to find more than two such cases reported, one by Schénborn and the other by Knowsley Thornton.

REGISTRATION OF GIPSIES AND VAN DWELLERS.

Ir does not reflect the greatest credit either on our social system or on the acumen of our legislators that the ele- mentary needs of whole communities have in some cases been practically omitted from the consideration which has provided for the rest of the population. As an example of this kind of neglect, we may quote the case of gipsies and other itinerant classes. Inhabitants of towns even in the slums have been afforded the privileges of efficient sani- tation and of education. As far as possible, a like pro- vision has been made for the population of canal boats ; but the gipsy and the van dweller, though nominally included within the scope of Acts drawn up in the interest of the nation as a whole, are practically exempted from their operation by the want of administrative machinery adapted to the conditions of their wandering life. The Education Act, while it applies itself with perhaps too great accuracy to the mental deficiencies of the more sedentary classes, is not sufficiently flexible to conform to the movements of these nomads. The sanitary authorities, on their part, take but little note whether four, five, or a dozen inmates occupy @ moving cabin just large enough for one or two. Perhaps they rely, with some show of reason, on the free life in the open air enjoyed by the van man during the day as an antidote to the slow carbonic poisoning which he under- goes at night. Notwithstanding the existence of this safety valve in the case of the healthy, however, it is obvious that it does not meet the always possible requirements of

illness. The course of infectious disease, once begun inside a close van, is likely to be a somewhat rapid one, since the atmosphere must at any time be far from pure. While, therefore, we cannot but admit that some practical diffi- culties must inevitably attend any legal regulation of the life and habits of these wanderers, we should like to see in operation, as effectually as might be, some measure for the registration of this class of people with a view to enabling them to share in the advantages—moral, mental, and physical—enjoyed by almost all their fellow countrymen.

INTERCOLONIAL MEDICAL CONGRESS, 1889.

Ir is announced that Dr. Mackellar of Sydney has resigned the chair of the Section of Medicine, which will be filled by the senior Vice-President, the Hon. Dr. Taylor of Brisbane. Addresses will be given by the presidents of all the Sections, and general meetings of Congress will be held for the dis- cussion of such subjects as hydatid disease, fevers in Australasia, Australasian climates, &c. Any members of the profession in the United Kingdom who may visit Melbourne at the time of the Congress will be associated with all its proceedings, and will, we are assured, be heartily welcomed. The Compagnie des Messageries Maritimes has consented to allow members of the Congress tickets from Marseilles to Melbourne at 30 per cent. under the usual rates, and to furnish tickets from London to Marseilles for five pounds. The agents of the Norddeutscher Lloyd have recommended their head office to similarly allow a discount of 20 per cent. on passages by their steamers. The San Francisco mail steamers will carry passengers from America to Sydney at 20 per cent. below the usual rates. For the protection of the companies, intending members of Congress are desired to furnish themselves with documents showing that they are members of the medical profession en route to the Congress. We urge on all medical men who can do so to accept the cordial welcome of the pro- moters of this Congress.

DRUNKENNESS AMONG CHILDREN.

ACCORDING to recent intelligence, the School Board of Vienna is placed in a painful position with regard to some of the school children. It appears that it is not uncommon for the children of poor parents to receive by way of break- fast nothing more than a glass of spirits, and even to appear in the school-room drunk. Instances of juvenile indulgence might be found in any country, and possibly in every social rank. The exposure of this wide and open prevalence of a vicious custom amongst the very youngest is, however, to most of us a new and startling revelation. One’s first impulse on having the facts thus presented is to conclude that they have been magnified by rumour. This hopeful view of the case is but natural. At the same time, it is hardly possible to suppose that the interference of the authorities is not actuated by a proved necessity for their action. If this be the case, the question arises, What means are best calculated to reach and destroy this injurious habit at its root? To prevent the sale of drink to young children is a cardinal principle in our own by no means oppressive liquor law. It is a measure worthy of introduction into other codes, and we may look to its operation, if applied, for some abatement of this most un- natural form of excess. Any law of this kind, however, can only partially control the circumstances of these Viennese children. Here the parent is the chief offender, and the morning dole of spirits is given as a substitute for food. It would be very difficult for any Government to stamp out this practice by repressive edicts, and a better result may probably be expected from the judicious efforts of the School Board, armed with necessary powers. In all

1036 THE LANCET,)

PUBLIC MORTUARIES.—YELLOW FEVER.

[Nov. 24, 1888,

such cases, however, it will be found that the introduction of the cheap loaf and of temperance principles, combined with a sympathetic interest on the part of the rich in the needs and struggles of the poor, will do more than twenty laws to bring about the desired reform.

RESINS USED BY THE ANCIENT EGYPTIANS.

A SMALL jar of resin was recently submitted to Mr. E. M. Holmes for identification by Mr. Flinders Petrie, of the Egypt Exploration Expedition. This jar, which was in a perfect state, was disinterred from a heap of rubbish found among the ruins of Naucratis and dates from the sixth century B.c. Naucratis was at this time the only Greek colony in Egypt, and it was through this town alone that trade with Greece was permitted. Mr. Holmes states in the Pharmaceutical Journal that the jar contained Chian turpentine. According to Fliickiger there is no evidence that the old Egyptians were acquainted with the resin. The discovery of this pot of resin carries the history of the commerce of the drug two hundred years further back. The other resin was found on a mummy cloth on the body of a person to all appearance of some rank. It was found in Hawara Cemetery, in the Fayum province of Lower Egypt, and it dates from a period not earlier than the second century A.D. On heating some of the resin in a flame, the vapours of benzoic acid were given off, and a decided vanilla odour was recognised. This points to the conclusion that the resin must be a Siam benzoin. The authors of the Pharmacographia state that there is no evidence that the Greeks and Romans, or even the earlier Arabian physicians, had any acquaintance with benzoin.

PUBLIC MORTUARIES.

THE need for public mortuaries has been well shown by recent events at Fulham, where a woman died suddenly from small-pox. The body was removed to a small lumber- room in the Fulham Cemetery, where there appears to be space for one shell only. The coroner, Dr. Diplock, held an inquest, but the medical man in attendance said he had intended to make a post-mortem examination, but there being no attendant and no light he was unable to carry out his intention. The inquest was therefore adjourned, and the body was removed to a shop in the main road, where the examination was conducted, the body not being buried owing to these circumstances until about nine days after death had taken place. The vestry, it is stated, have for two or three years been considering the need for a mortuary, but have evidently failed to provide their district with this necessity. Now that the attention of the inhabitants is roused by the risk to which they were undoubtedly put, it may be hoped the action of the authority will be quickened.

YELLOW FEVER.

AT the meeting of the Mississippi Valley Medical Associa- tion on Sept. 26th a discussion upon yellow fever took place, which was opened by Dr. Comegys of Cincinnati. At the close of the debate the subject was referred to a committee, which drafted resolutions to the following effect : — ‘‘ Resolved : That it is the sense of this meeting that yellow fever is not contagious in the ordinary sense of the term; that it cannot be communicated from the sick to the well, except in an atmosphere containing germs. That the mildness of the present yellow fever invasion, and the lateness of the season, warrant us in strongly deprecating the fear now existing in many southern communities, the present rate of mortality being not greater than that which ordinarily obtains in typhoid fever. That the self-imposed quarantine regula-

tions now in force in the States north of the infected districts are not only absurd, but inhuman and unworthy of the age in which we live. That the quarantine regulations, to be effective, should apply to the baggage, clothing, and effects, rather than to the person of the individual. That when such effects come from infected districts they should be destroyed by fire, and the owner reimbursed from the public funds. That cities and towns to the north and upon lines of travel may safely provide hospitals for the reception and cure of the sick.”

ANATOMICAL DISPLAYS.

THE police authorities have of late shown unusual zea} in repressing the public exposure of pictures unfit for exhibition on a common thoroughfare. The veto of the executive has, it seems, had special reference to anatomical diagrams and models. These are regarded as possessing for some minds a depraving tendency, and it must be allowed, in support of this reasoning, that a public street is not on any grounds entitled to the demonstrative privileges of the class-room. No tradesman is obliged to practise exposures of this kind in order to maintain his trade. His conduct, should he persist in this practice, need not, indeed, imply any obscene intention; yet it is injudicious. The officia} action, nevertheless, implies no censure. It merely pro- vides against a source of injury to public morality, and, if it seem somewhat tutorial, is fairly defensible on account of its purpose and the necessities of the case with whichi t deals. We would only add that it must, in fairness, proceed with equal freedom and with far greater firmness to deal with exhibitions of notoriously indecent character, such as from time to time disfigure the streets and windows of every large and many smaller towns.

SHOCK.

Dr. Davip CHEEVER of Boston maintains, in a paper read before the American Surgical Association, that the nausea following anesthetics, the prolonged duration of operations under anzsthetics, and the character of modern surgical dressings, all tend to produce a condition of ex- haustion or secondary ‘‘shock.” In his opinion this is one of the most serious drawbacks to modern surgery, and should be as far as possible guarded against—by never operating in cases of primary shock before reaction has set in; by tranquillising the fears of the patient; by giving alcohol before administering an anesthetic, and not pro- longing such administration more than is absolutely neces- sary; by operating as rapidly as is prudent, making the dressing as short as possible, and avoiding chilling the patient.

INOCULATION WITH LEPROSY.

THE letter of Archdeacon Wright to The Times (Nov. 19th) will have been read with painful interest. This gentleman, it may be remembered, lately called public attention to the spread of leprosy, and the evidence of its contagiousness. He now furnishes a report from the Board of Health, Honolulu, giving information of the con- dition of a condemned criminal at Oahu Gaol who was inoculated with leprosy by Dr. Arning on November 5th, 1885. Dr. Emerson, the President of the Board of Health, and Dr. Kimball examined this man on September 25th of the present year, and reported that he presented marked signs of tubercular leprosy. Archdeacon Wright thinks that this ‘‘ terrible experiment” goes far to prove the con- tagiousness of leprosy ; and there is no doubt that such an experiment is proof of its inoculability. But we venture to think that the case for contagion is not rendered any stronger than it was already by the facts of the disease and

THE LANCET,)

DANGER OF LARGE DOSES OF MALE FERN.

[Nov. 24, 1888. 1037

of its nature gathered from various sources of late years ; and it is questionable whether the transmission of such a disease by inoculation, even on a condemned criminal, is an experiment that ought rightly to have been made.

OPERATION FOR TORTICOLLIS.

Dr. LEVRAT has devised a new method of treating torticollis. Instead of operating subcutaneously, he cuts down upon the sternal tendon of the sterno-mastoid muscle, effected by a longitudinal incision two centimetres long. He clears the tendon with the forceps, passes a grooved director under it, and divides it. He then divides any tissue that may bind down the muscle at that spot, sutures the wound, and dresses it antiseptically with iodoform and gauze. Over the dressings he places the following apparatus. The head being enveloped in cotton wool, a silicated bandage is wound horizontally around it at the level of the forehead and a similar bandage vertically over the crown and uader the jaw. Where these bandages meet at the level of the mastoid process on the sound side, a small hook, with the concavity looking upwards, is inserted. Another silicated bandage is wound round the body below the axilla, and through the thickness of the bandage a hook is inserted in the middle line in front, having its concavity looking downwards. When the bandages have dried, the two hooks are connected by a band of indiarubber, which assists the sterno-mastoid of the sound side to keep up a continuous traction and so correct the deformity. This apparatus and the dressings are left untouched for fifteen days, and the success of the operation is said to be assured.

PROSECUTION UNDER THE DENTISTS ACT.

THE prosecution under the Dentists Act of Messrs. Huntley and Coe, for representing themselves as dentists without being registered, resulted in their conviction and a fine. The defence was that they had American qualifica- tions (D.D.S.), but that these particular ones were not regis- trable in this country; and it was insinuated that the members of the British Dental Association were actuated by motives of professional envy. The ease with which degrees could, and still can be, obtained at some dental colleges, and the short time requisite for graduation, rightly decided the Medical Council not to recognise such colleges, and the diplomas of only Harvard and Michigan are regis- trable. The charge of jealousy, when made against such well-known men as the representative board of the British Dental Association, needs no serious refutation. What the Americans in their own country think on the matter is shown by a recent resolution of the Harvard Dental Alumni Association to remove the names of some of its members who are connected with the American Dental Institution.

DANGER OF LARGE DOSES OF MALE FERN.

Dr. BAYER of Reichenberg, publishes in the Prager Medicinische Wochenschrift a case which has come under his observation in which very dangerous symptoms were pro- duced by extract of male fern together with extract of pomegranate. The patient was a woman of twenty-six years of age, who was suffering from tapeworm. She had been ordered by a medical man to take capsules each contain- ing 2°5 grammes of extract of male fern, along with the same quantity of extract of pomegranate. She took three of these capsules. Early in the morning, at intervals of an hour, they produced severe sickness, and a portion of the tapeworm came away. As, however, the head did not come, the patient proceeded to take four 1rore capsules, so that altogether she had taken 17 grammes of each of the two drugs. These set up violent vomiting and

diarrhea, which continued till late in the afternoon, with out, however, producing any further signs of the tapeworm She then became exceedingly faint and prostrate, and in the evening fell into a comatose condition, in which she lay for thirty hours, notwithstanding continued efforts to arouse her. When at last she awoke, she found that her left eye was blind. When it was examined the next day, the pupil? was found to be widely dilated, and quite inactive to light. The ophthalmoscopic examination revealed nothing abnor- mal; the pupil of the right eye reacted to light, but the acuteness of vision was diminished. After having been kept in the dark for forty-eight hours, the left eye was found to be sensitive to light, and as the patient regained strength vision gradually returned, and in a fortnight was nearly as good asever. Dr. Bayer concludes that Gerhardt’s advice never to give more than from five to ten grammes of extract of male fern should be rigidly adhered to.

THE GALEN CLUB.

Tuis club, which was formed in April last to serve as a medium of intercommunication between medical men, has closed its doors, the action being taken by the proprietor apparently in opposition to the wishes of the committee. The reason of its failure is probably not far to seek, being similar to that which has led to the extinction of earlier efforts in the same direction. The majority of medical men have very little time to devote to club life, and those few who are more fortunate in this respect prefer to mingle in a general social circle, rather than to patronise a purely pro- fessional club. That this idea pervaded the minds of those ruling ‘The Galen” was shown a short time since, when its name was altered to ‘‘ The Sackville,” and an endeavour made to attract other than professional candidates for entrance. Correspondence which has reached us from late members shows that there is considerable regret at the dis- persion of the nucleus that had already been formed, and the wishes of those who desire still to remain associated would probably be better met by some arrangement for their reception as a body into an older-established club, rather than by endeavouring, at least as yet, to found another exclusively medical institution.

DIPHTHERIA IN YORKTOWN, FARNBOROUGH.

In reference to this outbreak, we are enabled to state upon authority that, although there have been some cases and several deaths, they have been entirely confined to the children of College servants living in the villages of Camberley, Yorktown, and Sandhurst. There has been no case in either the Royal Military or the Staff College. Just now the health of the gentlemen cadets is exceptionally good.

THE PREVALENCE OF EPIDEMIC DISEASES.

WE are at the present moment receiving numerous accounts of local epidemics, and as to some of the prevail- ing diseases it is difficult to judge whether the excess of reports indicates an exceptional amount of disease or in- creased publicity, owing to the steadily growing interest which the public takes in such matters. From different parts of London we hear of considerable fatality from measles, and it is to be noted that, whereas in the week end- ing Sept. 29th there were thirty fatal attacks, the number of deaths has almost uniformly gone up since that date until the fatality reached 124 last week. In some districts the excessive, and at such times mischievous, energy of school- attendance officers is credited with a needless diffusion of infection. Diphtheria has also been prevalent in several places, and we regret to learn that it has again shown itself in the neighbourhood of Camberley in Surrey, to which

1038 THE LANCET,)

TENTS AND VANS.—F(CETAL BLOOD AT BIRTH.

(Noy. 24, 1888,

paragraph we refer more particularly in another column. In the Vyrnwy Valley a reappearance of the disease seems to have subsided. In Derby scarlatina has been making rapid. strides; the new hospital is not yet erected, and the disease is distributed about the town. The same disease has also appeared at New Brighton. To some of these occurrences we shall probably revert more in detail.

TENTS AND VANS.

A party of gipsies have temporarily settled in the neighbourhood of Dawson’s-hill, East Dulwich, where they have neither water supply nor any system of drainage or sanitary appliances, and scarlet fever has broken out amongst them. The encampment is near to private houses and a Board school where 600 children are in daily attend- ance. An evening contemporary, commenting on these facts, clamours for legislation to deal with such persons and their mode of life; it may be pointed out, however, that the Housing of the Working Classes Act, 1885, gives full power for such dwellings to be dealt with under Section 91 of the Public Health Act, and a sanitary authority may make bye-laws for promoting cleanliness in them, for preventing the spread of infectious disease by the persons inhabiting them, and generally for the prevention of nuisances; the same powers are conferred upon metropolitan sanitary authorities.

FCETAL BLOOD AT BIRTH.

Dr. SCHERENZISS of Dorpat has published some interest- ing observations on the condition of the blood at birth. The specific gravity is, he finds, markedly lower than that of the blood in the adult. The hemoglobin is also much less than in adult blood, the proportion being 76°8 to 100. The amount of fibrin is only about two-sevenths of that in the blood of the mother. Fcetal blood cannot be analysed quantitatively by washing with saline solutions, a large part of the constituents of the corpuscles which appear to be in a very loose state of combination, especially the hemoglobin, going over in the filtrate. Fetal blood is richer in saline matters than the blood of adults, especially in insolubfe salts. The sodium salts are somewhat greater in amount than in the blood of adults, but the potassium salts decidedly less. The sex and the weight of the child appear to have no influence on the quantitative constitution of the blood at birth.

SIR WILLIAM JENNER AND THE BRITISH MEDICAL ASSOCIATION. WE are requested by Sir William Jenner to state that he has resigned the membership of the British Medical Association.

FOREIGN UNIVERSITY INTELLIGENCE.

Dorpat.—Dr. Carl Dehio, extraordinary Professor, has been appointed Professor of Special Pathology and Clinical Medicine.

Freiburg.—Dr. Killian has qualified as privat-docent in Rhino-laryngology.

Gothenburg.—It is proposed to establish a university in this populous town. The present scheme, for which the funds are already obtained, provides only for a faculty of arts or philosophy. If a medical faculty is ever added, it will probably only be thought seriously of after the lapse of considerable time.

Graz.— Dr. Oscar Eberstaller has qualified as privat-docent in Anatomy.

Greifswald.—Dr. Hoffmann hascommenced work as privat- docent in Otology, and Dr. Ballowitz as privat-docent in Anatomy.

Halle.—The students have shown their gratification at the refusal of Professor Kaltenbach to migrate to Wurzburg by holding a torchlight procession in his honour.

Madrid.—Professor Calvo Martin has been obliged to resign the post of Dean on account of delicate health.

Montpellier.—Dr. Brousse has been appointed to the charge of the laboratory of clinical medicine. Dr. Carrieu has been appointed professor of Medical Pathology. Dr. Paulet has been appointed professor of Anatomy.

Padua.—Dr. Frari, professor of midwifery, has resigned on account of ill-health.

St. Petersburg (Military Medico-Chirurgical Academy).— A large number of names are mentioned in connexion with the vacancy in the Professorship of Surgery, caused by the death of Professor Bogdanovski. Amongst others may be mentioned those of Professor Pavloff of St. Petersburg, Pro- fessor Podrez of Kharkoff, and Dr. Sinitsin of Moscow. During the vacancy the clinical work is being performed by Dr. Multanovski, and the lectures are given by Dr. Krug- lievski. In a short time another Surgical chair will become vacant by the retirement of Professor Pelokhin, who has nearly completed his twenty-five years’ service. Dr. Korkunoff has been admitted as privat-docent in medicine and medical diagnosis.

Vienna.—The Professorship of Medicine vacated by the death of Professor von Bamberger is, it is said, to be given to Professor Schrétter, whose name is best known in con- nexion with laryngology. Professor Schriétter is, moreover, a general physician of great ability. His appointment is likely to be hailed with pleasure by English and American students, as he not only speaks English, but lectures in German in so simple a manner and with such distinctness of utterance that it is much more easy for a foreigner to understand him than many of the other teachers in Vienna. Meantime, the lectures at the late Professor Bamberger’s clinique are being delivered by Dr. Neusser.

DEATHS OF EMINENT FOREIGN MEDICAL MEN.

THE deaths of the following eminent foreign medical men are announced:—Dr. Gemmel, Privy Medical Councillor, of Posen.—Dr. Rudelf Maier, Professor of Pathological Anatomy in the University of Freiburg, and author of a well-known manual on that subject.

THE twelfth annual meeting of the American Academy of Medicine was held in the New York Hospital on the 13th and 14th inst.; and the sixteenth annual meeting of the American Public Health Association is being held this week at Milwaukee, Wis., from the 20th to 24th. In the latter Association the subjects selected for discussion were “‘The Pollution of Water Supplies,” ‘The Disposal of Refuse Matter of Cities,” ‘‘ Animal Diseases dangerous to Man,” and “‘ Maritime Quarantine, and Regulations for the Control of Contagious and Infectious Diseases, and their Mutual Relations.”

Mr. Epwarp Nunpy, L.R.C.S., L.S.A., Barrister-at- law, resident medical officer of the Royal South London Dispensary, is a candidate for the representation of West Lambeth on the School Board of London.

THE medical practitioners of Alsace-Lorraine are for- bidden to write their prescriptions in French. They must use either Latin or German.

ADVICES from Lisbon state that the island of Palma, one of the Canaries, is officially declared to be infected with yellow fever.

Tne LANCET,]

REPORT ON THE BRITISH EMIGRATION SERVICE.

[Nov. 24, 1888. 1039

The Aberdeen Herald and Weekly Free Press states that Dr. Russell, medical officer, Glasgow, has traced an outbreak of scarlet fever in the west-end of the city to the milk supply from a dairy, fourteen of the ninety-two families supplied by which were found to be infected.

THE Government of Canada have, on the proposal of the deputies of the province of Quebec, given the name “‘Pasteur” to a canton of the county of Kamouraska. The canton adjoins the State of Maine.

THE Council of the Royal Society have selected Professor Huxley as the recipient of the Copley medal for 1888. The medal will be presented at the anniversary meeting of the Society on Nov. 30th.

REPORT OF THE LANCET Special Sanitary Commission THE BRITISH EMIGRATION SERVICE.

In the ports of London, Liverpool, Glasgow, Hull, and at the Ministry of Marine in Paris, we have made inquiries concerning the regulations that affect the emigration services. From the officials whose duty it is to see that the stipulations of the Emigration Act are enforced, from the directors of some of the principal steamship com- panies, from the surgeons in charge of vessels, from the port sanitary authorities and from the medical officers of health in seaport towns, from passengers, emigrants, and crews, and from all persons who are affected by the Imperial Passengers Acts of 1855 and 1863, with their several appendices, we have received the same answer. In reply to questions, one and all urged that the Act was out of date and required revision. The reasors given differed considerably, according to the source whence they emanated. Sometimes the motives were absolutely con- tradictory. Officials often thought that there was insuffi- cient legislation, while some shipowners were alarmed at the page oo of ‘‘grandmotherly interference” on the part of the Government; but, in either case, it was admitted that the law as it now stands requires alteration, and also that the law is de facto to a large extent system- atically disregarded. For instance, in Clauses 35 and 36 of the Act a dietary table is given. This is not observed. The —- in many ships, are not rationed as there suggested. They are, we believe, much better fed. Instead of serving to each his allotted share, all are allowed to have as much as they can eat, whether they take more or less than the regulation amount. Any question of right for ship-owners to make the alterations is at once disposed of by Appendix L, p 106, of the Act. With the quick

effected in these days, and the modern facilities of carrying provisions, the diet of the emigrants can be advan’ usly chan, and improved. Still, the fact that the Act in this part is not observed, that ship-owners have of their own accord improved upon the Act, goes some way to show that it is now out of date. As another instance, we might mention the rules with regard to the medicine chest. These are altogether antiquated. The medicine chest must contain drugs no longer required, while others which the progress of medicine has proved to be urgently meeded are not included in the official list. Thus a doctor is obliged to carry with him medicines he does not want, and must trust to the liberality of the ship-owners to obtain what will be of real service to him. For instance, the list does not include such serviceable drugs as sp. ether. sulph., chlorate of potash, glycerine, tinctures of iodine, aconite, nux vomica, belladonna, diluted phosphoric acid, alum, mercurial ointment, salicylate of soda, iodoform, syrupi ferri phosp., syrupi ferri iodidi; no labels, no mustard leaves, no linseed meal, or any of recent antiseptic

dressing necessaries whatever; but it does contain opo- deldoe, saltpetre, Friar’s balsam, blistering paper, and any amount of salts, tartaric acid, and purging pills. We are informed, however, that since we commenced our inquiry on this subject measures have been taken into considera- tion by the authorities with a view to modifying and im- proving the contents of the medicine chest. Ye trust this information will prove correct, and that new regulations will be issued forthwith.

With regard to sanitary matters, there have also been great improvements effected since the Act was first framed, and we may {now reasonabl ane to enforce a much higher standard of comfort. That this can be done is practically demonstrated by our own colonial Governments. If the rules enforced by the Queensland, the New South Wales, and New Zealand Governments when chartering a ship are com- pared with our Emigration Act this fact will be rendered patent. Not only are the stipulations with regard to diet and to medical comforts drawn up on a much higher seale, but there is more breathing space allowed to each emigrant. Sixteen clear superficial feet instead of fifteen feet are allowed to each adult passenger, and even more during the hot season of the year; and, in addition, hospital and w.c. spaces are not included in that measurement. If the Act must be amended in so far as it governs the condition of ships, it must also be altogether altered with respect to the authorities that are to enforce its application. At present control and authority are so divided and often so ees ewan at times the result is utterly bewildering. This will me more apparent as we proceed to relate the result of our various experiences.

GLASGOW.

Commencing with the Port of Glasgow, we were at once met by Dr. Russell, the medical officer of health of the city, who acknowledged the unfairness of impos- ing on the comparatively small town of. Greenock the duty of shielding Glasgow from the danger of imported epidemics. As a ship enters the Clyde she must pass

reenock before she can reach Glasgow. The ngers, the crew, the cargo, are all going to Glasgow, yet it is the Greenock authorities who have to board the ship, and the Greenock ratepayers who must pay the cost. Thus a few weeks ago a ship arrived from America with five cases of small-pox on board. It was the Greenock authorities who had to remove these patients, treat them in their fever hos-

ital, disinfect the ship, and pay the entire cost; while the nhabitants of Glasgow, who were far more interested in the matter, incurred no outlay. Nothing remained to be done save to take the addresses of the passengers and crew, and warn the local — authorities of the places where they intended to reside that the new comers should be carefully watched. It may be worth while noting that, in this case, the passengers and crew amounted in all to 110 persons. They were vaccinated and went to reside in ten different localities; not a single case of small-pox occurred among them. This ship paid no port dues or rate to the Greenock authorities, but to the Glasgow authorities, because it was at the latter town that she went into om Evidently there should be but one authority and a uniform rate for the whole of the Clyde.

At Glasgow the control exercised over emigrant ships does not seem to be so severe as elsewhere. In Liver- pool a cattle ship is not allowed to clear in less than seven days, but in Glasgow there is no such restriction, and the Board of Trade have no medical adviser who can enforce the required control. Should a steamer which has just conveyed cattle over the Atlantic be converted, in a few hours, into a mger ship, there is no one

ualified to see that this hasty transformation is free

m danger. Anybody may be called in and simply asked if they notice any unwholesome smell, and of course, with a plentiful use of disinfectants, no such smell is noticed. There is no medical evidence forthcoming to support the entering of a case against the owner. Again, when the ship leaves the town, its bill of health is signed by an officer of the Customs, who of course knows nothing whatever of the health of the town. There may be a a epidemic in the very district where the emigrants are lodged ; the only person officially acquainted with the facts would be the medical officer of health of the town, and he does not sign the ship’s bill of health; he is not even consulted. But the medical officer of health does control the condition of the lodging-houses or depots where

=

1040 {THE LANCET,]

REPORT ON THE BRITISH EMIGRATION SERVICE.

(Nov. 24, 1888.

the emigrants put up while waiting for their ship to sail. In Glasgow we visited some of these lodging-houses, and the result was not altogether satisfactory. The sleeping accommodation was very good, the beds and bedding clean, and very rigorous measures are taken to prevent overcrowding and to keep the sexes apart. The emigrant depéts are open to inspection both day and night. But, technically speaking, the drainage is not satisfactory. In one lodging-house there were fixed washing-stands in each room, with pipes communicating directly to the drains. There was no trap.visible ; if it existed, it was embedded in the wall, and therefore inaccessible, and could not be cleaned if it should happen to be stopped up. Our faith in the possibility of these pipes being properly arranged was very

@onsiderably shaken by finding upstairs two closets situated |

In the port of Glasgow we inspected several ships, and one ship in particular had very detective accommodation for emigrants. It was a Wednesday when we went on board, and the ship was advertised to start for America on the Saturday, yet the painters had not commenced to work. The paint would therefore be wet when the ship started, and this would add considerably to the nauseating odours that prevail on board. We are not prepared to say that the measurements of space below deck for the emigrants were under the stipulations of the Act, but we do assert that they are altogether insufficient for the requirements of health, not to mention decency. On both sides were cabins partitioned off from the centre, where seats and a table for meals &c. were situated. The first cabin, as represented in a sketch made of general berthing

Fic. 1.

General view of berthing arrangements on the main dx k' f

in the centre of the building between two rows 0 bed- rooms. These closets are absolutely dark; they have no windows opening on to the outside, and must ventilate into e@ passages and bedrooms. These technical and grave defects are all the more regrettable, as in every other respect the depét is admirably kept. The rooms are lofty, the light and ventilation excellent ; and, when there is an extra crowd of emigrants, a large meeting hall is divided off with movable wooden itions and converted into a dormitory. On both sides there are lofty windows, and thus a flood of light and a through a are readily secured to purify the place. Another lodging-house, uented exclusively by foreigners, has also a closet which does not communicate with the outer air, but ven- tilates in a The closet has been built in a corner of a bedroom, from which it is walled off merely by a wooden ition, and receives light from a little window giving in to the bedroom. This is, of course, altogether wrong. At the same time this depét has for the general use of emigrants closets outside the house, away from all possibility of mischief, which are perfectly ventilated and effectively capes. There is some difticulty in enforcing these technicalities of drainage. Convictions cannot be easily obtained on a question of a trap or of ventilation, magis- trates not being technically qualified to judge such matters. But we cannot insist too much on their importance. The ingress of sewer air from a lavatory pipe or a badly con- structed closet will, of course, destroy all the good effects due to cleanliness and the prevention of overcrowding.

acmigiant ship, cne side being only half,ccmplete.

Fy ts on the main deck of an emigrant ship, had two rows of bunks, containing four berths each. (Fig...)

Fic. 2. 2 er 2 eT 2 eT 2 er z feu #6 = 2 2 a2 a a o SFT

It measured 8 ft. 3in. by 8 ft. 4in., and 7ft. 9in. in height. The diameter of the side scuttles was Qin. The next

| | {

THE LANCET,] REPORT ON THE BRITISH EMIGRATION SERVICE. (Nov. 24, 1888. 1041 and most of the other cabins had double the number of | sanitary condition of the whole ship is thus gravely com- bunks—that is, eight on each side—with a passage between | promised. Of course it will be answered that the health of which measured only 2ft. 3in. in width. Thus we have the travellers is excellent; that casesofzymoticdiseaserarely, sixteen ple lying down in bunks 6 ft. 2in. long, so if ever, occur. This is natural enough. The journey is so narrow that there would not be room in them for a stout short that the passengers have not time to develop, but man, and a single passage dividing the sixteen re this | only to take in, the seeds of disease. The question to passage being only 2 ft. 3in. wide. This will be better | answer is what number of persons are taken ill after understood by referring to the accompanying plan. (Fig. 2.) | reaching their destination, and on this point, though of As the side scuttles are generally closed—in fact, can only | vital importance, there is no record whatever. The second be opened in really fine weather,—these cabins ventilate into | or lower deck of this same ship is also used for emigrants, the centre portion of the deck by an aperture that runs | and here the state of affairs for want of ventilation is even along the top of the partition, and is from 8 in. to 9 in. wide. | worse, while the difficulty of getting to the closets and The section of the ship and the view of the steerage, the temptation to soil the alley-way are even greater. partially fitted up, which accompany this report, will enable On reaching the deck we found that the closets were on the reader to realise the position at once. (Fig. 3.) The the trough system, and consisted of five seats without any

Fic.

3.

Deck closets and hospital.

WaterLine ~----

Midship section of emigrant ship.

gratings over the hatchway that give air to this central part of the ship have to be covered over when the weather is bad; that is precisely the time when most of the emi- ts are ill. Soon the little narrow passage between the unks becomes fouled with vomit. Then there are no closets below deck. Women, children, and men have to struggle up on deck to reach the closets. As a matter of fact, and though this is contrary to all regulations and to the ship's discipline, passengers sometimes make use of the alley-way which forms a sort of gutter round the side of the ship. This alley-way or gutter in bad weather is soon oe with vomit, urine, and fecal matter, and it gradually drains down into the bilge. Now, there is no such thing as steerage bilge. Class distinc- tions cannot be maintained in what is practically the ship’s sewer. Consequently the bilge thus befouled through the overcrowding and insufficient accommoda- tions of the emigrants’ quarters floats all over the ship’s hold, gradually evolves putrescent gases, which travel upwards, ———— the health of not merely | the steerage but the first-class passengers. The |

partition, therefore devoid of priv; On one side were the closets for women, on the opposite those used by the men ; and in the same deck houses containing the two sets of closets are the two hospitals provided for the ship. Each hospital (one for women, one for men) has four s. Con- sequently, if during a case of accouchement another woman were to fall ill with fever, she would have to be placed side by side with the former case. Evidently there should be either four, or at least three, hospitals on board, so that the infectious cases as well as the different sexes could be separated. The construction of hospitals in the same deck house as the closets, separated from the closets only by a more or less imperfect partition, is an act of neglect. The latter portion of Clause 21 of the Imperial Passengers Act says: ‘No part of any berth shall be placed within nine inches of any watercloset erected in the between decks.” This sanitary provision is clearly evaded in spirit, if not in the letter, by placing w.c.’s and hospitals in such close juxtaposition on deck. Nor should women and children

compelled to come up on deck in all weathers and where there is no shelter. Some sort of accommodation should

— > Al ---- Cargo space and hold. Screw alley. Keel

1042 THE LANCET,)

A MEMORIAL —THE STATISTICAL SOCIETY.

[Nov. 24, 1888.

be provided below; and where a watercloset cannot be constructed, the pail system or ash closet could easily be introduced.

In Glasgow we further examined specimens of the stores, food, &c., provided for emigrants, and these seemed satis- factory. On board the Norwegian, an Allen line steamer, we had the satistaction of noting that a sanitary steward had been appointed whose exclusive duty it was to see after the cleanliness of the closets. The division of responsibility in such matters is often the cause of much disorder. In several other respects, notably with regard to the taking on shore and carefully cleaning, after each voyage, the surgical instru- ments, this company deserves praise; and the principle of making one man responsible for each department is carried out extensively. It is an excellent method of avoiding and of checking all forms of neglect and inefficiency.

MEMORIAL TO THE PRESIDENT AND COUNCIL OF THE BRITISH MEDICAL ASSOCIATION.

THE memorialists will feel obliged to the Editors of THE LANCET if they can find space for the insertion of the accom- panying document in the next number of their journal.

Nov. 17th, 1888.

Copy of Memorial to the President and Council of the British Medical Association.

The undersigned members of the British Medical Asso- ciation and others beg to direct the attention of the President and Council to the publication in the 1450th number of the Journal of the Association of the facsimile of a “script” by the late Emperor Frederick of Germany, referring to his treatment by one of his medical attendants. The publication of this document the undersigned regard as a violation of professional confidence, and its appearance in the British Medwal Journal as discreditable to the medical profession of this country. They accordingly request the President and Council to take such immediate action as may be required to clear the Association and profession from the discredit now attaching to them in respect to this matter.

Sir Risdon Bennett, F.R.S. | Dr. Allchin.

Sir Henry Pitman. Dr. oo.

Sir George Paget, K.C.B.,| Dr. F. Taylor. F.R.S. Dr. John Williams.

Dr. George Johnson, F.R.S. | Dr. Barlow.

Sir Edward Sieveking. Dr. G. W. Pitt

Sir Alfred Garrod, F.R.S. SirJames Paget, Bart., F.R.S.

Dr. Munk. John Marshall, F.R.S.

*Dr. Matthews Duncan,| *Sir Joseph Lister, Bart., F.R.S. F.R.S.

Dr. Wilks, F.R.S. *William S. Savory, F.R.S.

Dr. Russell Reynolds, F.R.S.| *John Eric Erichsen, F.R.S.

Dr. Robert Martin. George Pollock.

Dr. Dickinson. Sir Joseph Fayrer, F.R.S.

Dr. Pavy, F.R.S. Sir W. Mac Cormac.

Dr. Andrew. Charles A. Aikin.

Dr. James Pollock. *Thomas Bryant.

*Sir Dyce Duckworth. Sydney Jones.

Dr. Broadbent. J. W. Hulke, F.R.S. Dr. Playfair. George Lawson.

Dr. Douglas Powell. *Thomas Smith.

Dr. Cheadle. Berkeley Hill.

Dr. Pye-Smith. John Croft.

Dr. Sturges. *Dr. Robert Liveing. Dr. Edward Liveing, Sir George H. Porter. J. F. Banks, M.D. Sir William Stokes. Samuel Gordon, M.D. Ed. H. Bennett, M.D. J. Emmerson Reynolds, M.D. J. Magee Finny, M.D. J. Cunningham, M.D. Dr. Ord. C. J. Symonds. Dr. Norman Moore. W. A. Meredith. * Anyone wishing to join in this Memorial is requested to communicate with one of those in'this list whose name is marked with an asterisk,

Christopher Heath. Arthur Durham. Alfred Willett.

W. Morrant Baker. John Langton.

J. Pickering Pick. Charles Drage. Warrington Haward. H. G. Howse. Edward Owen, Pearce Gould.

THE STATISTICAL SOCIETY.

THE session of the Statistical Society was on Tuesday last opened by the President (Surgeon-General T. Graham Balfour, M.D., F.R.S.) with an address in which the highly necessary lesson of caution and exactitude in the use of figures was enforced with singular felicity of illustration. The fact that statistics may be grievously misread and figures made to prove anything has long since been suffi- ciently clearly recognised to pass into a proverb. But this general knowledge of the fact does by no means avail to protect even writers of reputation from becoming the victims of strangely mistaken deductions from statistical data and proceeding to invest crude and fanciful theories with the authority of mathematical propositions. The most common error of those who misapply figures is doubtless that which Dr. Balfour aptly calls ‘‘the neglect of the principle of cateris paribus.” Figures which have something in common are incautiously assumed to have all things in common, and if the result confirms an opinion ante- cedently formed, it is apt to be accepted as con- clusive proof. The following passage from a paper im the Scotsman affords a striking illustration, and furnished one of the most telling points in Dr. Balfour’s address= “It is stated, on the authority of the Director-General of the Army Medical Department, that ‘in the period from 1860-64 inclusive no fewer than 32,324 examinations of recruits were made by army surgeons. The number of mem required averaged 6465, this being a small one, and the fact therefore telling in favour of rigid tests being applied to ensure the efliciency of the material offered in the shape of fighting men. The rejections from all causes numbered 371°67 per 1000. The next period, from 1882-86, presents. us with 132,563 men who offered themselves for enlistment. The rejections here amounted to 415°58 per 1000. The increase in the rejections was therefore of a most marked character. Sir Thou Crawford can explain it in one way only: ‘The masses from whom the army recruits are chiefly taken, he tells us, are of an inferior physique to what they were twenty-five years ’ That is the plain unvarnished truth, and as such it is by no means of a palat- able kind to those who regard the national welfare as a thing: to be conserved and prized.’” That looks like a highly authoritative statement, and it isno doubt correct, so far as. mere figures go; but Dr. Balfour, who brought an accurate knowledge of the processes by which the figures had been produced to bear upon their examination, was able to show that, when due allowance is made for changes in the: official methods of compiling the statistics the comparison yields no such inference as that deduced, but, on the con- trary, to show that if the comparison is made betweem strictly analogous classes of men the proportion of rejections is lower, and considerably lower, at the later period than at: the earlier. What is true of this case is true of every other, and the importance of a careful regard to this fact, and the frequency of its neglect by such as ‘‘ should know better, ” were most aio and forcefully exhibited in Dr. Balfour's paper. We heartily congratulate the author upon the skill and success with which he has invested an ol subject with new significance.

BERI-BERI.

Tue Administration Report for the Straits Settlements (Penang and Malacca) contains the following reference to this disease :—

Beri-beri, the disease which has — so fatal among the Netherlands Indian troops in Achin, and which has been prevalent from time to time among Chinese coolies at tin-mining centres in the Malay peninsula, has by no means disappeared from this settlement, though it is satisfacto to be able to note that the deaths in hospital from this disease were fewer in 1887 than in previous years. In a pauper hospital like ours, which is the refuge of paupers of alt nationalities, many of whom have contracted disease in — beyond the colony, beri-beri must naturally be loo: or.

Tse LANcET,]

HEALTH OF ENGLISH AND SCOTCH TOWNS.

(Nov. 24, 1888. 1043

The statistics of the beri-beri cases in the pauper hospital for the last four years are as follows :—

Cases treated. Deaths.

At the Balik Pulau Hospital, the number of cases treated for this disease has diminished, though the death-rate has cemained stationary. The figures are as follows:—

Cases treated. Deaths. Percentage.

In Province Wellesley, too, a marked decrease is re- — in beri-beri cases, the total number being 95, with

deaths, or a death-rate of nearly 9 per cent. In Province Wellesley, the treatment advocated by Dr. Kynsey of Ceylon has been tried with good results. The prison was entirely free from beri-beri during the year. The last outbreak there was in 1880.

VITAL STATISTICS.

OF ENGLISH TOWNS.

In twenty-eight of the largest English towns 5582 births and 3553 deaths were registered during the week ending Nov. 17th. The annual rate of mortality, which had been 21°8, 19°6, and 19-0 per 1000 in the preceding three weeks, rose again last week to 19°7. During the first seven weeks of the current quarter the death-rate in these towns averaged 20-0, and was 0:7 below the mean rate in the corresponding periods of the ten years 1878-87. The lowest rates in these towns last week were 12°6 in Brighton, 14:1 in Bristol, 149 in Leicester, and 16°3 in Nottingham. The rates in the other towns ranged upwards to 24°3 in Wolverhampton, 24°7 in Manchester, 26°3 in Blackburn, and 29°3 in Cardiff. The deaths referred to the principal zymotic diseases, which had been 467 and 432 in the preceding two weeks, rose last week to 495; they included 212 from measles, 62 from scarlet fever, 62 from diphtheria, 55 from whooping-cough, 452 from diarrhea, 51 from ‘‘fever” (principally enteric), and only one from small-pox. No death from any of these zymotic diseases was registered last week in Halifax, whereas they caused the highest death-rates in Salford, Blackburn, and Cardiff. Measles showed the greatest mortality in Oldham, Wolverhampton, Blackburn, and Cardiff; scarlet fever in Salford and Blackburn; whooping-cough in Cardiff; and “fever” in Manchester, Salford, and Blackburn. The 62 deaths from diphtheria in the twenty-eight towns included 44 in London, 5 in Salford, 4 in Manchester, 4 in Nottingham, and 2 in Birmingham. Small-pox caused one death in Cardiff, but not one in London or in any of the twenty-six other great towns. The

Metropolitan Asylum Hospitals and the Highgate Small- pox Hospital contained no small-pox patient during the week. The number of scarlet-fever patients in the Metro-

politan Asylum Hospitals and in the London Fever Hospital was 1080, against 1007 and 969 in the preceding two weeks ; 83 cases were admitted during the week, inst 71 and $5 in the previous two weeks. The deaths referred to diseases of the respiratory organs in London, which had been 522, 441, and 373 in the preceding three weeks, were last week 374, and were 61 below the corrected ave The causes of 71, or 2°0 per cent., of the deaths in the twenty-eight towns last week were not certified either by a vegistered medical practitioner or by a coroner. All the causes of death were duly certified in Bradford, Brighton, Blackburn, and in seven other smaller towns. The largest of uncertified deaths were registered in Sheffield, underland, Salford, and Hull.

HEALTH OF SCOTCH TOWNS.

The annual rate of mortality in the eight Scotch towns, which had been 18°7 and 19°1 per 1000 in the preceding two weeks, was again 19°] in the week ending Nov. 17th ; this rate was 0°6 below the mean rate during the same week in the twenty-eight large English towns. The rates

in these Scotch towns ranged from 15° and 15-4 in Edinburgh and Leith to 24°6 in Dundee and 37‘9 in Paisley. The 484 deaths in the eight towns corresponded with the number in the previous week, and included 24 which were referred to measles, 11 to diphtheria, 10 to diarrhea, 8 to searlet fever, § to ‘‘fever” (principally enteric), 4 to whoo econ and not one to small-pox; in all, 63 deaths resulted from these principal zymotic diseases, against 56 and 70 in the preceding two weeks. These 63 deaths were equal to an annual rate of 2°5 per 1000, which exceeded by 0°3 the mean rate from the same diseases in the twenty- eight English towns; this rate ranged in the eight towns from 0°0 and 1-2 in Leith and Edinburgh to 41 in Greenock and 16°9 in Paisley. The fatal cases of measles, which had been 26, 23, and 27 in the preceding three weeks, declined again last week to 24, of which 18 occurred in Paisley, 3 in Glasgow, and 3 in Greenock. The 11 deaths from diphtheria showed a further increase upon recent weekly numbers, and included 6 in Glasgow and 3 in Edinburgh. The deaths attributed to diarrhea, which had been 20 and 9 in the previous week, rose again last week to 10. All the 4 fatal cases of whooping-cough and 6 of the 8 deaths from scarlet fever were returned in Glasgow. The deaths referred to “ fever,” which had been 3 and 8 in the previous two weeks, declined last week to 6, of which 2 occurred in Aberdeen and 2in Paisley. The deaths referred to acute diseases of the respiratory organs in the eight towns, which had been 114, 98, and 84 in the preceding three weeks, were last week 97, and were 47 below the number in the corresponding week of last year. The causes of 59, or more than 12 per cent., of the deaths registered in the eight towns during the week were not certified.

HEALTH OF DUBLIN.

The rate of mortality in Dublin, which had been 21°9, 24°4, and 27°5 per 1000 in the preceding three weeks, de- clined again to 23°5 in the week ending Nov. 17th. During the first seven weeks of the current quarter the death-rate in the city averaged 2471 per 1000, the mean rate during the same period being 19°2 in London and 15°5 in Edin- burgh. e 159 deaths in Dublin last week showed a decline of 27 from the number in the previous week, and included 6 which were referred to whooping-cough, 5 to measles, 5 to diarrhea, 3 to ‘“‘fever” (typhus, enteric, or ill-defined), 1 to scarlet fever, and not one either to small-pox or diphtheria. Thus 20 deaths resulted from these principal zymotic diseases, against 21 in each uf the preceding two weeks; these were equal to an annual rate of 3°0 per 1000, the rate from the same diseases being 3°0 in London and 12 in Edinburgh. The fatal cases of whooping-cough and diarrhea showed an increase upon the numbers in the previous week, while the deaths from “fever,” which had been 10 in each of the preceding two weeks, declined last week to3. The deaths both of infants and of elderly persons showed a slight decline from the numbers in the previous week. Four inquest cases and five deaths from violence were registered ; and 43, or more than a quarter, of the deaths occurred in public institu- tions. The causes of 21, or nearly 14 per cent., of the deaths in the city were not certified.

THE SERVICES.

Army MepicaL Starr. — Brigade Surgeon William Tanner has retired on temporary half-pay on account of ill- health (dated Nov. 7th, 1888).

ArMy MEDICAL RESERVE OF OFFICERS.—The_ under- mentioned Acting Surgeons to be Surgeons, ranking as Captains (dated Nov. 2st, 1888): John James de Zouche Marshall, Ist Cinque Ports Rifle Volunteer Corps, and David Thomson, M.D., 3rd Volunteer Battalion, the Bedfordshire Regiment.

ADMIRALTY.—In accordance with the provisions of Her Majesty’s Order in Council of April Ist, 1881, Staff Surgeon Penrose John Barcroft has been allowed to withdraw from Her Majesty’s Naval Service with a gratuity.

The following appointments have been made :—Surgeon Edward H. Williams, to the Duke of Wellington (dated Sept. 26th, 1888); Surgeon Frederick J. Barns, M.D., to the Mariner, and Surgeon James Bradley, to the Jackal (both dated Nov. 19th, 1888); and Richard B. Wrightson,

| Percentage. |

[Nov. 24, 1888.

and Thorpe (dated Nov. 19th, 1888).

VOLUNTEER Corps.—Artillery: 2nd Lancashire: Hugh Richard Jones, M.B., to be Acting Surgeon (dated Nov. 17th, 1888).—lst Renfrew and Dumbarton: Wm. A. McLachlan, M.D., to be Acting Surgeon (dated Nov. 17th, 1888). Engineers: The following Officers are transferred from the Ist Newcastle-on-Tyne and Durham Engineer Volunteer Corps, on its division into two Corps—viz.: Acting Sur- geons: W. Mearns, M.D., and F. W. Gibbon, to be Acting Surgeons (dated Nov. 17th, 1888).—Rifle: 2nd Volunteer Battalion, the Sherwood Foresters (Derbyshire Regiment): Acting Surgeon R. Bennet, M.D., resigns his appointment (dated Nov. 17th, 1888).—Ist London (City of London Rifle Volunteer Brigade): Acting Surgeon A. J. Hubbard, M.B., resigns his appointment (dated Nov. 17th, 1888).

Correspondence,

“ Audi alteram partem.”

COMPARATIVE SURGERY. To the Editors of Tu& LANCET.

Srrs,—There can be little doubt about the fitness and advisability of Mr. Macnamara’s proposal, that candidates for the Membership of the Royal College of Surgeons of England should in future submit themselves to examina- tion tests as to their training and manipulative skill in surgical operations. The implied compliment of the examinee to the examiner, ‘“‘ That in operative cases I should immediately send for you,” has yet lost none of its relish; but an examination in surgery ought to be an examination in handiwork, and not the occasion for omitting every real practical test in operating with the hands. Under the present circumstances of omission, practical teachers in surgery find themselves hors de combat, and their working yupils deprived of the opportunity of showing their merit. ‘his reform in examinations may be considered to be im- practicable. I maintain that the Government can supply more bodies than would be required under the present powers of the Anatomy Act; even in case of its being unable to do so, there is no difficulty in getting an exten- sion of that Act. It is presumable, amongst so many millions who surrender their bodies for teaching purposes when alive, that there would be some who might permit their bodies to be also utilised for teaching purposes after death, an example of this nature having recently occurred at the Westminster Hospital. My present object is to suggest that comparative surgery could be substituted for human surgery in bridging over an occasional difti- culty of procuring bodies, and at the same time fairly test the dexterity of the candidate. These operations would be performed in every instance on the dead animal ; in- dividual structures that are wasted or used in manufacture in the ordinary course of trade would be utilised.

For example: (1) the use of the saw, drill, or trephine, the wiring of fragments, the removal of spiculie, or the treatment of cartilage or periosteum can be as faithfully represented on the dead bones of a sleep as on those of the human subject; (2) tenotomy can be performed on the tendo Achillis of any dead animal; (3) the use of the knife and director can be demonstrated on the abdomen of any cadaver, as can also the varying forms of intestinal suture; (4) wounds of the skin can be manufactured and treated on the carcases of lower animals according to ordinary surgical rules; (5) tracheotomy, laryngotomy, and removal of foreign bodies can be shown post mortem on any fair-sized windpipe; (6) ophthalmic surgery and practice can be exemplified on the lifeless eyes of a pig, bullock, or horse; (7) the removal of needles, shot, bullet, or foreign bodies from artificially made wounds on the cadaver can be undertaken on any lower animal; and (8) the handling of the sheaths of vessels and the ligature of arteries can be well illustrated on any dead animal.

The adoption of Mr. Macnamara’s resolution will drive another hard hit at the system of ‘‘ grinding.” The neces- sary preliminary training of the candidate and the essen- tially practical tone of the examination would not be of a character favourable to students, being set as alarums to go off at the warning of the examination bell. Believing

that this new departure in examination conduct must strengthen the hand and teaching of both pupil and master, I trust that its acceptance may be shown to be not only advisable, but also practicable. I am, Sirs, your obedient servant, Welbeck-street, W., Nov. 20th, 1888. RicHArRD Davy.

MENSTRUATION AND THE OVARIES. To the Editors of THE LANCET.

Srrs.—I have now going through the press a large work in which this subject is discussed at length, and I therefore can hardly expect you to give me space for more than a skeleton statement, prefaced by a question addressed to my friend Dr. Barnes—Upon what ground does he use the expression ‘‘ old aw,” which declares that the ovaries rule over the function of menstruation? A daw is the final stage of evolution at which arrives what was first a working hypothesis, and afterwards a theory; a law has a universal acceptance, but this ‘‘old law” is a mere statement which arose in 1827, and has been perpetuated by the custom of text-books (i.e., copying blindfold from one another) ever since, until it has got ingrained into professional belief and stands there as fully established as is the belief, on the part of the public of the origin of the Gordius from a horsehair. I ask anyone to read Ritchie’s papers in the Medical Times and Gazette of 1843 pupae | in his son’s book in 1875), Reeves Jackson’s papers, or those of Kesteven, and, finally, some contributions of my own, of Arthur Johnstone, and Bland Sutton, and then ask him- self the question, Will the ovular theory of Menstruation stand? ‘The uniform answer will be that it will not, and for the following among other reasons. Ovulation in the human animal occurs at irregular intervals, and probably not more than twice or three times a year, aot not at monthly intervals, as had been believed until recently. Ovulation begins before birth, goes on all through life, and does not entirely cease even in extreme senility; wJeereas menstruation is connected with certain conditions of the uterus and Fallopian tubes (see Johnstone and Sutton) which are not concurrent with ovulation, but are limited to the time of life between puberty and the climacteric. Menstruation occurs only when true Fallopian tubes are found, and is the result (Johnstone) of the erect position. What have hitherto been regarded as Fallopian tubes, in non-menstruating animals, are only bifid uteri, and are not, either structurally or in any other way, analogous to the human Fallopian tubes. In countless thousands of animals ovulation produces nothing like the appearances of mens- truation, but the assumption of the erect position and the appearance of ciliated Fallopian tubes are concurrent with the appearance of menstruation. The popular belief that menstruation is the same thing as the estrus of the lower animals is a delusion (Arthur Farre, in Todd and Bowman's ‘ Encyclopedia”—an article the convincing and cogent reasoning of which has been strangely over- tooked). The influence of the Fallopian tubes in being at least the starting point of the phenomena of mens- truation is shown (a) by the almost constant symptom of precedent pain in cases of occlusion of the tubes ; and (b) by the appearance of the menstrual discharge in the clamp cicatrix before its appearance from the uterus. Complete removal of both ovaries, without injury to the tubes, has little or no influence in arresting menstruation. Complete removal of the tubes, without injury to the ovaries, arrests menstruation at once, and completely in about 80 per cent. of the cases. Complete removal of both tubes and ovaries arrests menstruation at once, and completely in 95 per cent. of the cases. Complete removal of both ovaries and tubes together, with removal of the uterus as completely as possible (as in Porro’s operation), may leave menstruation absolutely uninterfered with. This is the fact in at least three eases known tome. The conclusion to be drawn from all this is that the old statement that the ovaries rule the function of menstruation is not based on fact, and that we must con- elude that the origin of the function is situated in some nerve centre not yet discovered. My own belief is that Arthur Johnstone has gone a long = in arriving at the truth in pointing out the importance of including the large nerve trunk which lies in the angle between the tube and the round ligament when we perform the operation of removal of the uterine appendages. I had arrived at the

1044 Tue Lancer,] MENSTRUATION AND THE OVARIES. M.D., to be Surgeon and Agent at Ald a ee —— =

THE LANCET,

CANCER OF THE RECTUM.—CAUSE OF CRAMP.

(Nov. 24, 1888. 1045

same conclusion when I said (twelve years ago, for the first time) that the tubes had more to do with menstruation than had the ovaries. This was ridiculed (by Martin, of Berlin, and others) as ‘‘ Tait’s tubular theory,” but it is substantiated by the complete confirmation of the further facts which I then laid down—(a) that inflammatory and eystic diseases of the tubes always influence menstruation by deranging it, increasing its frequency and its amount, and rendering its performance excessively, often agonisingly, painful; and (db) that diseases of the ovaries themselves B not affect menstruation in the least. Finally, if ovulation (or the ovaries) rule the function of menstruation, removal of one ovary should diminish its frequency very per- ceptibly (for ovulation is not symmetrical), but no such result is apparent. Menstruation is therefore clearly independent of ovulation, just as the building and furnishing of a house are independent of its being inhabited. Menstruation is “‘nidation,” the building and furnishing, the making ready for a tenant if one comes along. As Arthur Johnstone beautifully and in a perfect way puts it, the house is swept out and cleaned once a month ready for a tenant, but there is only a chance of a tenant two or three times a year ; and then there is another conditioa—impregnation—necessa for the occupation of the domicile. Thanks to Johnstone's brilliant discovery, we have this mass of intolerable con- fusion reduced to a divine simplicity.

May I beg, then, of your readers who are concerned in the preparation of text-books of physiology and of the diseases of women to give this subject fair play, and its modern literature a serious study? They will then discontinue the absurd reiteration of statements sixty years old, which have not a single fact to support them.

i am, Sirs, yours Xc.,

Birmingham, Nov. 17th, 1888. Lawson TAIT.

CASE OF CANCER OF THE RECTUM: SEQUEL. To the Editors of THe LANCET.

Srrs,—In THE LANCET of Oct. Ist, 1887, I contributed a case of ‘‘ Cancer of the Rectum; Excision; Recovery.” As I think it advisable that the sequel of such cases should be made known, I now send you briefly the further history of the one referred to.

There was not the least indication of recurrence of the disease in the parts operated upon, or in their neighbour- hood, which continued quite healthy in structure and function (with the exception latterly of occasional fecal —— in the rectum) until the patient’s death, which took place on the first of last month—viz., one year and ten months and a half after the operation. In the early part of March this year—i.e., nearly sixteen months after excision—I was asked to see the patient, and found an enlarged inguinal gland on the right side. This having increased somewhat rapidly on May Ist, at my suggestion she went to London A consulted SirJames Paget with regard especially to the feasibility of its removal by operation. His opinion was decidedly against this. Until this period, and for some time afterwards, her general health continued good in every respect. The tumour increased in size, ulcerated, and pursued the ordinary course of cancerous disease, until the occurrence of free haemorrhage, which, as already stated, terminated fatally on Oct. Ist. One ques- tion of interest here arises, whether the ‘“‘small, not hard, inguinal nodule in the right groin, which appeared to be innocent in character,” mentioned in the report of the case, had, after remaining quiescent for so long a period, any- thing to do with the subsequent appearance of the disease in that region. I can hardly think so. It was not larger than a small split pea apparently, as it was doubtless at that time innocent in character. A circumstance worthy of note was the remarkable exemption from pain throughout the whole progress of the case, with the exception of a burn- ing sensation in the edges of the wound after the dressings, which was more or less subdued by ointments of morphia or cocaine. For some time before death even these were not required, and she continued almost without suffering until the hzmorrhage which terminated her life. As I had found from my own experience and that recorded by others that, whatever other effect Chian turpentine may have had, diminution of pain appeared to follow its use. I gavethis drug in large doses, with, I need not say, in such a case, but feeble hope of other material benefit. The absence of acute suffer- ing was certainly remarkable, to whatever this was due;

and I could not but observe that, after taking the drug for a time, the sloughing process extended its destructive action into the hard mass of diseased structure, with but little encroachment upon the more healthy tissues surrounding. How far this result was promoted by the agency of the Chian turpentine is of course an open question. The medi- cine agreed well with the stomach, and was followed by a marked sense of comfort. I am, Sirs, yours faithfully, Swansea, Nov. 10th, 1888. GEORGE PADLEY.

THE CAUSE OF CRAMP. To the Editors of Tue LANCET.

Sirs,—While reading in your issue of Nov. 10th the article on Cramp and Allied Affections, I could not help remarking that most of the instances cited as being due to pressure are equally capable of explanation by supposing a. poison circulating in the blood. The feeling of languor and ill-being so common in dyspeptics is usually, I believe, attributed to that cause; is it not reasonable to push the point a line further, till we arrive at veritable cramp? ** Hard cheese, shell fish, &c.,” are notoriously indigestible. Again, violent muscular exercise sets free in the muscle tissue products of muscle waste, which are harmful to the fibres themselves ; and doubtless the cramps are, in such cases, due to these products of muscle waste being too slowly got rid of. s to predisposing causes, we should expect anything that tends to lower the general tone of the body to predispose that body to be affected the more easily by exciting causes. So doubtless a phthisical patient, after undue muscular exercise, might expect cramp with less chance of disappointment than a healthy man. While speaking of remedies, the author of the article gives it as. his ave that in a severe case of cramp refusing to yield to other remedies, chloroform must not be used if there be heart or kidney disease. Now the author has seen such cases terminate fatally from syncope due to pain. Is it not a safe rule among operating surgeons that, if chloroform is likely to kill, the pain of the operation is more likely to do so? I take it that in the case of cramp the pain stands in very much the same relation to the general rationale of the thing as does the pain of an operation; that this indicates that the patient is more likely to die without chloroform than with it, and forces one to the conclusion that chloro- form should be used.

I am, Sirs, yours faithfully, WILLIAM WoopwarbD, M.R.C.S. Ena.

Lostwithiel, November, 1888.

RINGER’S THERAPEUTICS: STRANGE ADVICE. To the Editors of Tuk LANCET. Srrs,—-Under the article “‘Aconite” in the above book, llth Ed., p. 453, the following appears. Speaking of the use of aconite in searlet fever, it is said: ‘‘ It is well, there- fore, during the convalescent stage to direct the nurse to take the temperature night and morning, and if this should rise beyond the healthy standard, she should at once give aconite, so as not to allow some hours to elapse before the patient can be visited by the medical attendant.” Surely those who have given aconite know that it is a drug whose effects on a child's system require the most careful watching. Here a nurse is told to administer aconite—the dose or doses not mentioned—to a patient who is supposed to be developing ‘‘ acute inflammation of the kidneys.” It is to be hoped ‘‘ the nurse” will have sufficient sense not to do so, else she may have reasons for doubting her power not only to prescribe but to administer so very active a poison, especially when a medical practitioner or ‘‘ attendant ” can be easily called in.—I am, Sirs, yours truly, : Ropert R. RENTOUL. Hartington-road, Liverpool, 8., Nov. 18th, 1888.

PRESENTATION.—Dr. C. J. Wharry, the Super- intendent of the Government Civil Hospital, Hong Kong, on the oceasion of his leaving the service, has been pre- sented by the members of the hospital staff, as a mark of their esteem, with an address, accompanied by a locket and chain, the former bearing a suitable inscription. At the same time a handsome gold bracelet was presented to Mrs. Wharry.

1046 LANCET,)

NORTHERN NOTES.—EDINBURGH.—DUBLIN.

(Nov. 24, 1888.

NORTHERN COUNTIES NOTES. (From our own Correspondent.)

UNIVERSITY OF DURHAM.

THE final examinations for degrees in medicine and surgery are fixed to commence on Monday, Dec. 3rd. The list of candidates is along one. Dr. Charlton Bastian and Professor Annandale are the appointed foreign ex- aminers. The annual dinner of the students of the College of Medicine was held at the County Hotel on Tuesday last, and passed off with great spirit. The chair was occupied by Professor Philipson, and the vice-chair by Dr. T. C. Nesham. A greater number of students were present than usual, and Drs. Limont, Horace, Page, and others contributed to the harmony of a very pleasant evening.

THE CASE OF QUADRUPLETS AT SUNDERLAND.

Her Majesty the Queen has graciously sent Mrs. McGrady, of Monkwearmouth, a gift of £3, notwithstanding the death of the four children to which the poor woman had recently given birth.

ACCIDENTS TO WORKMEN IN THE NORTH.

The records of the northern coroners’ courts for the last few days show the great risks to which workmen in the north are exposed, and the perilous nature of their employ- ments. On Saturday last a man about forty died in the Jarrow Memorial Hospital. He was engaged attending to an iron furnace, when a large sheet of flame burst out, completely enveloping the poor fellow, whose clothes were burnt off his body, scorching him in a shocking manner, and causing his death in a few hours. A fatal accident also took place last week to a workman at the Middlesbrough Chemical Works. While mae a bichrome tank he slipped, and his right foot and leg dropped into the liquid. ‘The limb was washed after the accident, and he was taken to the North Ormsby Cottage Hospital ; but as he showed symptoms of searlet fever, he was removed to the Fever

ospital, where he died. Dr. Malcomson, the medical officer, said the death was due to the effects of bichrome, which is an irritant poison.

MIDDLESBROUGH,

The old custom of accompanying the newly elected Mayor to church was observed at Middlesbrough on last Sunday, and quite an imposing procession was formed. The col- lection made at the church was on behalf of the infirmary and hospitals of the town.

DEATH OF DR. JACKSON OF NEWCASTLE.

I regret to notice the death of Dr. Edward Jackson of this city, which took place yesterday after a short illness. Dr. Jackson was a graduate of the London University, M.R.C.S., and L.S.A. As a student he received the Fellowes gold medal at University College Hospital, and the silver medal of the Apothecaries’ Society. e was a native of Shettield, where he was best known, being one of the founders of the Women’s Hospital there. About seven years ago he retired from practice in Sheffield, but retained his connexion with the Women’s Hospital as honorary consulting surgeon. He died at his residence in the Jesmond suburb of New- castle, and if he practised at all there it was not actively.

Newcastle-on-Tyne, Nov. 20th.

EDINBURGH. (From our own Correspondent.)

PROPOSED NEW MICROSCOPICAL SOCIETY.

‘Ir is proposed to form a Microscopical Society in Edinburgh—a society in which microscopists of all kinds may meet and discuss such points as they have in common. A preliminary meeting has already been held, at which a small committee was appointed to collect information and report. Those who are taking an active part in this matter —amongst whom are the President of the Royal College of Physicians (Dr. Peel Ritchie), Professors Greenfield, Annandale, and Balfour, Drs. Affleck, Woodhead, Buist, Hunter, Edington, and McFadyean, and Mr. Forgan—are agreed, so far as can be gathered, as to the general lines on

which the society should be carried on, but little is as yet decided as to details. It is very probable that, if such a society could be constituted so as to work along with some of the other medical and scientific bodies, it could be made a most valuable means of stimulating microscopical research. Why should it not be, for instance, a peripatetic society, holding each of its meetings as one of the regular meetings of a society interested in the subject to be dis- cussed. The Pathological Club, which is said to be in a most vigorous condition, is “‘ run” on some such plan as this. ANTI-VIVISECTIONISTS IN EDINBURGH.

It isa pity that the “twenty” well-intentioned but very much misguided ladies who on Thursday last met, in- terested in the suppression of cruelty, especially of so- called scientific cruelty, to confer with the Rev. A. Noble. Scott, President of the North British Anti-Vivisection Society, should not make themselves actually acquainted with the objects and work of the institutions which they attack. The chairman, at least, has no good excuse for ignorance, for he must have seen reported in the daily papers the results of researches carried on in the labora- tories against which he fulminates, embodied in papers read before the Royal Society of Edinburgh and elsewhere. In not one single instance do the researches (italicised b the rev. chairman) involve a case of vivisection. In suc straits do the anti-vivisectionists find themselves for argu- ment that they have recourse to the time-honoured story of the dog whose timidity so touched the hearts of the students in the physiological class that they begged for its life. It would be interesting to find out how often this story has been made to do duty in Edinburgh, London, and elsewhere during the last twenty years. Neither medical students nor physiologists are brutes, and they would be as ready as anyone to revolt against wanton cruelty to animals. It is a curious reflection on the false senti- mentalism of our age that it has to be recorded that there is never a word uttered against the cruelty to animals involved in coursing, hunting, shooting, and other forms of ‘‘ amuse- ment,” whilst weakly sentimental people rave against what they term ‘‘ scientific cruelty,” a term without any actual meaning. There is more suffering inflicted by a small shoot- ing party ina day on the moors than is met with in con- nexion with the work carried on in all the laboratories in Great Britain during a whole year.

Edinburgh, Nov. 21st.

DUBLIN. (From our own Correspondent.)

ROYAL ACADEMY OF MEDICINE IN IRELAND.

THE opening meeting of the Medical Section was held on the 16th inst., when Dr. Lombe Atthill, the President of the College of Physicians (who is President of the Medical Section of the Academy), gave a short address on the action of drugs in uterine affections. He appeared to think, from some observations made, that ergot administered during the early months of 7 ay my | had no effect on the uterus,

r. John Byrne

a statement which could not endorse. In eases of amenorrhea he had found the permanganate of potash an unreliable remedy, and Dr. William Moore also corroborated this view. Mr. Arthur Benson exhibited a rare case—an example of albuminuric retinitis occurring in only one eye.

THE AMALGAMATION OF THE MEDICAL SCHOOLS.

I have been informed that the opposition offered by one of the proprietors of the Carmichael School, to prevent that institution joining the scheme of amalgamation, will be fatal to the pro measure unless some arrangement is agreed upon by the contending ies. It is probable, however, that a friendly agreement will ultimately be come to between those interested in the matter, and that the scheme will be adopted at no distant period. As 8 the alleged illegality of transferring the Carmichael Pri Fund (some £2000) for the benefit of the new school, I cannot understand, if this be so, what parties will partici in the benefit if not the students of the combined schoo

A QUESTION OF COMPENSATION.

On Monday, the 19th inst., in the Exchequer Divi the Court gave judgment in reference to the application

THE LANCET,)

DUBLIN.—PARIS.

[Nov. 24, 1888. 1047

Dr. Pye, Professor of Anatomy and Physiology in the Queen’s College, Galway, for compensation for loss of fees arising out of the dissolution of the late Queen’s University. It appears that before the passing of the University Education Act, 1879, Dr. Pye’s fixed stipend was £220 per annum, and also certain fees from the students attending his lectures, amounting on an average to £500 a year. The effect of the dissolution was that he ceased to a professor of the University, but continued a professor of the College; as it was not compulsory, however, for students to attend his lectures who were candidates for — in the Royal University, his fees decreased considerably, and he sought compensation for the loss he had sustained. The Lord Chief Baron gave judgment for the Crown. His Lordship said that the office which Dr. Pye had held in the Queen’s University was dis- tinct from that which he held in the Queen’s College. In respect of his office in the University he received certain emoluments, amounting to £20 yearly, and he now received in the Royal University larger remuneration for similar work. As to the office held in the College, that was not within the section of the statute, nor was he deprived of it. Judgment for the Crown should be given with costs, and this decision was concurred in by Mr. Baron Dowse and Mr. Justice Andrews. HEALTH OF IRELAND.

The birth-rate for the September quarter was 1°6 under the average rate for the corresponding quarter of the past ten years ; and the death-rate was 0°9 under the rate for the same

riod. Deaths from the principal zymotic diseases were considerably below the average. Compared with the corre- sponding quarter of 1887, the returns of pauperism, furnished by the 1 Government Board, show a decrease of 1370, or 3°l per cent., in the average number of workhouse inmates on Saturdays during the quarter, and a decrease of 1117, or ot ag cent., in the average number of persons on out-door relief.

Dr. Wm. Moore, has been appointed

Dublin, Nov. 20th.

hysician to Her Majesty in Irelard, igh Sheriff for Antrim County for 1889.

PARIS. (From our own Correspondent.)

THE PASTEUR INSTITUTE.

WITH reference to your note in THE LANCET of last week anent the opening of the new Pasteur Institute, the following may be found interesting to your readers. After the eulogistic speech of M. Bertrand, Perpetual Secretary of the Academy of Sciences, on the scientific work of M. Pasteur, covering a period of nearly half a century, Dr. Grancher, M. Pasteur’s principal coadjutor at the institute, read the report of the number of persons that underwent the anti-rabic treatment at Paris during the years 1886-87 and the first half of 1888, which amounted to 5384. In 1886, when the afflux of foreigners was considerable, 2682 persons were inoculated, 1778 in 1887, and 914 in the first six months of 1888. The mortality, counting all the deaths, even those affected with rabies on the day following the treatment, was—for 1886, ‘1°34 per cent. ; for 1887, 1°12; and for 1888,0°77. These figures are taken from theregister to Oct, 31st, 1888. But the mortality among the persons who succumbed to rabies within the fifteen days following the treatment had, of course, to be excluded, as the inoculation to be efficacious should be carried out before the incubation of the virus of the dog which had bitten the subject had commenced in the nervous centres ; for the virus of common rabies, trans- mitted directly to the surface of the brain of a dog, there incubates during fifteen or eighteen days before producing its effects. In the patients who dpantinted to rabies within fifteen days after the treatment the latter had been useless, simply because it had been commenced too late. Excluding these cases, the mortality, notwithstanding the treatment. falls for 1886 to 0°93 per cent., for 1887 to 0°67 per cent., and for 1888 to 0°55 per cent. This gradual diminution in the mortality is due to the progressive perfecting of the first steps of the treatment. Dr. Grancher explained that the treatment now adopted is more energetic, more pro- statistics from foreign parts, at St. Petersburg, Odessa, Moscow, Warsaw, Charkow, Milan, Palermo,

en Havana, and Rio Janeiro, accord with the statistics collected at Paris. He recalled the special report for 1887, which was drawn up by the Council of Hygiene from docu- ments at the Prefecture of Police, concerning the persons who were inoculated at M. Pasteur’s laboratory. In 1887 the number of persons bitten and inoculated amounted to 306, of whom three died, which gives a mortality of 0-97 per cent- On the other hand, seven cases of death from rabies occurred among the forty-four persons enumerated in the police lists as not having undergone the anti-rabic inoculation. In this group the mortality attains 15°90 per cent., which figure M. Pasteur and the Council had accepted as representing the average mortality before the adoption of inoculation. In concluding his report, Dr. Grancher said he wished it to be understood that the Pasteur Institute had been founded not only for the treatment of rabies, bui also for the purpose of promoting the scientific study of the means to practically combat the maladies which decimate the human species, such as diphtheria, typhoid fever, phthisis, &e. The vast laboratories attached to the institute will be open to medical men of all nationalities, where they will be taught the _— not only of anti-rabic inoculations, but of miecro- iological science in general. A regular staff has already been formed who will be the coadjutors of M. Pasteur at the institute. Drs. Grancher, Chantemesse, Charrin, and Terrillon are to attend to the treatment of rabies ; M. Duclaux, Professor of Biological Chemistry at the Faculty of Sciences, will direct the bacteriological laboratory ; M. Chamberland will be charged with the science of micro- logy in its relation with hygiene; Dr. Roux will teach the microbian methods in their applications to medicine; and two Russian savants, Drs. Metchnikoff and Gamaleia, will devote themselves to the morphology of inferior organisms, including comparative microbia. The institute is com- of two principal buildings, each with its own le, the principal one in the Rue Dutet, and the other in the Rue des Fourneaux. The first contains the apartments of M. Pasteur and his assistants, and in the chief hall may be seen the busts of the Emperors of Russia, Dom Pedro of Brazil, Baron Rothschild, Madame Boucicault, and M. de Laubespin, the chief subscribers to the institute. In the second building are to be found rooms. for inoculations and various laboratories. Here also are kept. the animals intended for experiments. At the close of the ceremony of the inauguration of the institute the President of the Republic, who presided on the occasion, confe on Drs. Grancher and Duclaux the dignity of Officer of the Legion of Honour, and on Dr. Chantemesse that of Cheva- lier of the Legion of Honour. It may here be noted that M. Pasteur, who is Commander of the Legion of Honour, possesses fifteen other decorations; he is member of eighty- three foreign learned societies, and holds the honorary Doctor’s degree of nearly every foreign University, and yet: he is not a tor of Medicine of any faculty.

DEATH OF DR. FREMY.

Dr. Charles Frémy, honorary physician of hospitals, died on the 19th inst., in the seventy-second year of his age. The deceased was first cousin to M. Edmond Frémy, Mem- ber of the Institute and Director of the Museum of Natural History. He was the father of M. Henry Frémy, who is at the present time on a scientific mission to America. Dr. Charles Frémy was the author of several remarkable works on the treatment of typhoid fever.

TREATMENT OF DIPHTHERIA.

At the last meeting of the Hospitals Medical Society M. Gaucher gave additional evidence in support of a line of treatment for diphtheria which he had brought under the notice of the Society last January. It consists in the appli- cation of strong alcoholic solution of carbolie acid (50 er cent.) to the surface which has been denuded of f membrane. The application is made three times a day, and in addition the mouth is frequently well rinsed with an aqueous solution of carbolic acid (1 per cent.). The method indicates a return to the old plan of cauterisation, and the results quoted by M. Gaucher, which included a series of eighty cases treated on this plan by M. Dubousquet,, are reported as having been very satisfactory. There was no inflammatory reaction, nor any symptom of carbolic acid poisoning, although there was usually carboluria.

STROPHANTHINE. M. G. Sée finds that strophanthine is a valuable remed in cases of mitral disease, especially in stenosis, but that it

1048 THE LANCET,)

OBITUARY.

[Nov. 24, 1888.

is unsuitable in aortic disease. Under its use the pulse gains in force and improves in'rhythm. It is the same in eases of cardiac dilatation and arterial-sclerosis, but in angina pectoris the drug is contra-indieated. M. Dujardin- Beaumetz recommended that strophanthus should pre- scribed rather than strophanthine, of which no fewer than five varieties occur in commerce. Paris, Nov. 20th,

Obituary.

HEINRICH VON BAMBERGER.

ON the 9th inst., at Vienna, as mentioned in our last issue, died Dr. H. von Bamberger, aulic councillor (Hofrath), and head of the second medical clinique of the Viennese school, after a severe illness of several weeks’ duration.

He was born on Dee. 27th, 1822, on the family estate in the vicinity of Prague. That city, as afterwards Vienna, was the scene of his studies, which, after a brilliant course, culminated in his graduation and appointment as assistant physician in the Prague General Hospital. In 1850 he went to Vienna, to work with Oppolzer there ; and in 1854 he accepted the post of Professor of Clinical Medicine and pri- marius physician in the Julius Hospital at Wiirzburg. On Oppolzer’s death he returned to Vienna, and in the spring of 1872 was appointed director of the Medical Clinique of the General Hospital. His call to Oppolzer’s chair was keenly opposed by the friendsof Kérner, who used all the then Minister Virezeks influence in their candidate’s favour; but Bamberger’s claims were too powerful even for Government partiality, and his success in the post more than justified the widen of his selection. His high intellectual gifts, his clear and logical exposition, particularly at the bedside, combined with his profound medical knowledge to make him an ornament of his professoriate, which soon acquired a far more than local fame by the co-operation (invited and obtained by himself) of the not less richly endowed Noth- nagel. His plain unaffected demeanour, his noble earnest- ness, also worked powerfully in his favour, so that it was difficult to say whether he was more honoured by the pupils who flocked to him from all parts of the world, or more beloved by the patients of low as of high degree who had the benefit, without distinction, of his care and skill. He was an ardent and unwearied worker in the domain of pathology, as is notably evinced by his publications on the ‘‘ Diseases of the Chylopoiétic System” and on the *“‘ Ailments of the Heart.” like Liebig, like Virchow, and like many of his most distinguished colleagues in science, and particularly in medicine, he had a dee and discriminating admiration for the great Englis pioneer of modern inductive research, and his ‘ Bacon von Verulam, besonders vom Medicinischen Standpunkt” (‘Bacon of Verulam, especially from the Medical Stand- point”), deserves the study of our profession, too negligent, it is to be feared, of the author of the ‘‘ Novum Organum.” Bamberger’s activity in medical journalism was immense, and aselection from his papers of more permanent value would be indeed a boon, not to his compatriots alone.

The latter years of his life were embittered by the tragic fate of his son, a youth of noble promise, Richard von Bam- berger, destined, like his father, for the medical career. On July 13th, 1884, the young man started on an ascent of the Schneeberg (Bavaria), and was never heard of more. A year passed in unremitting search, but not a trace of him was to be found. Only on July 18th, 1885, some forest rangers in the Frauenbachgraben, in the neighbourhood of the Great Héllenthal, at the foot of the Schneeberg, came upon some remains and effects which were recognised as belonging to the Viennese Professor's son.

On the 10th inst., Professor Nothnagel, on the assemblin of his class, alluded to the death of his colleague and frien in language of which the following, contributed by a student who was present, may be taken as a faithful tran- script: ‘It is often said that medicine is at once a science and an art; and the remark is nowhere more just than on the clinical side. We have great clinicians in whom scientific aptitude and power of thought are but little developed, but who seem gifted with the inspiration of the artist. Most commonly endowed with a far-reaching memory, there suddenly flashes on them a series of recol-

lections, ending, though often unwittingly, in a comparison with the concrete case and in a brilliantly improvised diagnosis. The feats of such clinicians lie more in the domain of practice than in that of literary exposition. With others, on the contrary, the rigid methodical discipline, the scientifically trained thinking power, is the Ariadne’s thread which runs through their clinical activity, their medical art, their scientific work. Bamberger belonged to those happily constituted natures in which both endowments are represented. His special power as a clinician and as a consultant may be briefly summarised in this—that he thought as a savant and practised as an artist. Therein lies the secret of his fame as physician, as diagnostician, and as clinical teacher. In the uprearing of the scientific clinical schools of Germany, Bamberger co-operated in the front rank—Bamberger, and Frerichs, who was his nearest intellectual brother among German clinicians. In both, the fine, artistic, plastic skill in the treatment of clinical henomena was dominated by the anatomical and physio- ogical thinking power which won the admiration of all their professional brethren. Bamberger’s work on cardiac ailments and on the derangements of the chylopoiétic viscera are unequalled specimens of clinical conception and een i dy while, again, what he was as a teacher is <nown to the many thousands of his pupils, who admired his centripetal penetration in the most complicated cases, who were awe-struck at his vast experience, who were charmed by the masterly ease and perspicuity of his exposi- tion. Science has lost one of her most outstanding votaries, the Vienna school one of its most shining stars. The name of Bamberger, the clinician, links itself brilliantly to those of Skoda and Oppolzer. With him has one of the lights gone out which Cieed to diffuse the lustre of the second great school of Vienna. Be honour and undying recognition to his Manes !”

GEORGE BORLASE CHILDS, F.R.C.S. Ena. (EXAM.).

Mr. BorLASE CHILDS, until recently a prominent surgeon in the City of London, where he was surgeon-in-chief to the Police Force for forty-one years, and to the City of London Militia (4th Battalion of the Royal Fusiliers) for over thirty years, and for many years surgeon to the Metropolitan Free Hospital and to the Great Northern Railway, died of liver disease on the 8th inst., and was interred at Kensal- green on the 13th inst. His funeral was attended by several personal friends, and his coffin was borne to the grave by sergeants of the City Police Force, more than seventy of whom were present. He leaves a widow, one son in the Colonial Service, and two daughters to mourn their loss.

Mr. Childs was born at Liskeard in 1816, of parents of considerable standing and repute in the county of Cornwall. He received a g classical education at the grammar school of his native town, and was subsequently apprenticed to a successful practitioner, Mr. Vincent, of Camborne where he had great opportunities for acquiring surgical experience in the treatment of mining accidents. On coming to London he attended the lectures at the Alders- gate School of Medicine, under the Graingers, Pereira, and others, and the practice of the Westminster Hospital. He became a Member of the College of Surgeons in 1838, and was appointed house surgeon of the Margate Sea- bathing Infirmary. Eight years after this he passed the Fellowship examination at the College, and commenced

ractice in London, where he attracted the attention of Mtr. Coulson, whom he frequently assisted in his larger operations. He quickly gained considerable reputation as a successful lithotomist. When he became surgeon to the Metropolitan Free Hospital he was one of the earliest English surgeons to employ subcutaneous tenotomy for deformities of the foot, even suggesting the advisability of dividing the muscles for spinal curvature. In 1853 he performed what we believe was the first successful ovariotomy, an operation which had been ag times attempted in both the Metropolitan Free

St. Mary’s Hospitals so unsuccessfully that most of the leading surgeons at that period considered it to be an altogether unwarrantable operation. But he will be best remembered as surgeon to the Great Northern Railway and City of London Police, for it was in organising the medical departments of these institutions that he displayed on a larger field the same forethought and ingenuity which secured the success of his surgical operations. Mr. Childs

TuHeE LANCET,)

OBITUARY.—MEDICAL NEWS.

[Nov. 24, 1888. 1049

took great interest in the sanitary and physical well-bein of the City policemen. He devoted much thought an attention to the selection of men for the force, and to their proper housing and clothing. He introduced the present lice helmet, gaiters, &c., and established the City Police Hospital, which at first met with much opposition on all sides, but now is highly valued. Besides his talent for organising, Mr. Childs had the tact and temper for ruling and leading bodies of men. He would have made a smart and successful officer in the army, and was always fond of his military duties. His social qualities were of a high order. He was in every sense a gentleman. He took a warm interest in the theatrical profession, wrote several | plays for, and was one of the founders of, the Royal matic College. His open, cheerful, and obliging dis- position won the love and esteem of his colleagues, friends, and patients. In consequence of a fall from his horse several years since he became somewhat deaf, but bore his infirmity with wonderful equanimity and _ resignation. Unfortunately for his friends, about two years ago he was tempted to accept a pension and to retire into private life; otherwise we believe his life might have been prolonged, and his friends and patients would not now have to deplore the loss of his cheerful and useful society.

JOHN CHALMERS, M.D. GLasc.

Ir is our sad duty to announce the death of Dr. Chalmers, which occurred in his house in Keppel-street, Russell-square, on the 9th inst. He died of septicemia, caused, in all pro- bability, by infection which was introduced into the system through a suppurating corn.

Dr. Chalmers studied medicine in the University of Glas- gow, and there graduated M.B. (with commendation) in 1867. During his student days in Scotland he was obliged, by hard necessity, to earn by literary and other work, unconnected with his professional studies, the means wherewith his personal and college expenses were met. That is a condition of things by no means uncommon amongst the students at Scottish universities. It was pro- bably in the hard conditions of his college life that he acquired, or at all events greatly strengthened, that strong sense of the sacredness of duty and of the need for self-sacrifice which so clearly marked his character, and controlled to a remarkable extent his discharge of his every-day work. After graduating in 1867, Chalmers spent a couple of years as assistant to a medical prac- titioner in Yorkshire. Just nineteen years ago he came to London and began to practise at Stoke Newington, whence in a short time he removed to the north of London, where he worked until the time of his death. In the early days of his London life he studied at St. Burtholomew’s Hospital, and in 1871 took his Doctor’s degree at Glasgow. In the metropolis practice soon came to him, and not a few of his patients became his close friends. To those who knew him well there was a peculiar charm in Dr. Chalmers’ character. His information was of the most varied kind, and, when he chose, he could talk in a way which made him a delightful companion, for he had a con- siderable fund of that quiet, somewhat grim humour which is so marked a trait of the Scottish people.

On the professional side of his life Dr. Chalmers showed a wide knowledge of medicine, and was keenly interested in the outcome of modern scientific investigation. This was especially so with regard to various forms of septic infec- tion—as, indeed, was but natural in one who had beena Glasgow student. When we remember that he was a very busy man, carrying on a large general practice, and find that he took time for that kind of work ; and when it is known, as we happen to know, that of late years, and up to the time of his last illness, he was engaged in working diligently and carefully at an investigation of various — in connexion with vaccination,—it does seem, in

ace of all that, hard that a man with tastes of that kind should be cut off to a very great extent from scientific work simply because the conditions of the life of a general — of medicine make it, as a rule, impossible for

im to do much more than his daily round of professional work. In that work he spared himself neither day nor night ; and in a large number of cases he gave his services asa doctor freely and willingly, knowing fall well that for these he could not expect from the rer class any money payment. It was while attending one of these

cases, about nine years ago, that he poisoned his finger, and from the effects of that unfortunate accident he never paputty recovered. We never heard that Dr. Chalmers nad an enemy ; we are certain he never deserved to have one.

J. ALEX. AITKENS, M.R.C.S., L.R.C.P. Epin.

WE record with great regret the death of Mr. John Alexander Aitkens, of Coventry, from scarlet fever—a sad reminder of the fact brought out by Dr. Ogle that the mortality of medical men from this disease is nearly four times that of the general population at ages over twenty. Mr. Aitkens was the affectionate and beloved son of Mr. John Aitkens, of Lincoln’s-inn-fields, and of Twickenham. He was born on the 17th of July, 1853, at Hans-place, Sloane-street, London. He was educated at the Guildford Grammar School, Surrey, under the Rev. H. G. Merriman, D.D., head master. He studied medicine at King’s College, and was dresser to the late Sir William Fergusson. Soon after obtaining his qualifications he was appointed house -surgeon to the Coventry and Warwickshire Hospital. He held this post till 1883, and in later years that of honorary surgeon, with great satisfaction to the governing authorities and patients of the hospital. Thereafter he commenced private practice, in which he was engaged when overtaken by his fatal ill- ness. Mr. Aitkens was buried at Brompton Cemetery, on Friday, the 16th inst., where numerous wreaths from Coventry assured his family that they were not alone in their grief and sorrow. We may not quarrel with the fortunes of medical war. We wrestle with disease, and if we are sometimes worsted we have the satisfaction of knowing that we die at our post, and that the wrestlers are oftener victorious than beaten. Mr. Aitkens seemed to have years of life and usefulness before him. But they have been cut short—not, however, before he had acquired the respect and gratitude of those amongst whom he laboured vik hanoer and success. He has left no wife or child to mourn his death, which is intensely felt by his. — and by his two sisters, who lived with him at ‘oventry.

Medical

University oF Lonpon.—The following candidates have passed the recent M.B. Examination :—

First Division.—John Hill Abram, University Colleges, Liverpool and London ; Samuel King Alcock, St. Bartholomew's Hospital; Evel Oliver Ashe, London Hospital ; Percy Ashworth, B.Sc., Owens Coll. and Manchester Royal Infirmary; James Thomas Bays, St. Mary's Hospital; Robert Bird, St. Bartholomew's Hospital; John Rose Bradford, D.Sc., University College; Ernest Henry Brock, Guy's Hospital; Weldon Cragg Carter, University College ; Jas. Jackson Clarke, St. Mary’s Hospital; Herbert E. Crook, Guy’s Hospital ; Henry Percy Dean, B.Sc., Hilarion M. Fernando, B.Sc., and John Lacy Firth, of University College ; Alfred fo" Francis, St. Bar- tholomew’s Hospital; John Edwin Gould, University College ; Alfdo. A. Kanthack, B.A., B.Sc., Liverpool Royal Infirmary and St. Bartholomew’s; Priestley Leech, Owens College; A. Lyndon, St. Bartholomew's Hospital ; Hy. J. Macevoy, B.Sc., St. Thomas's Hospital ; William Job Maillard, Guy's Hospital ; Ludovie William Darra Mair, St. Bartholomew's Hospital; William Page May, B.Sc. University College ; Geo. Hartley O'Reilly, Northampton Generai Infirmary and King’s College ; Alfred Parkin, Sore Hospital ; John Porter Parkinson, University College; Bedford Pierce, St. Bar- tholomew’s Hospital; Wm. Bramwell Ransom, B.Sc., University College ; John Lloyd Roberts, B.A., B.Se., and Harold Kennaway Roper, Guy’s Hospital; Harry Arthur Sansom and R, Vaughan Solly, St. Thomas’s Hospital; Ernest Henry Starling, Guy’s Hos-

ital; Walter Carless Swayne, Bristol Medical School and Guy's

{fospital ; John Herbert Tonking, St. Thomas's Hos ital; James A. Wheeler, Guy’s Hospital; Gilbert Benj. Mower White, University College ; John Wilkie, B.Se., St. Bartholomew's and Brompton Com sumption Hospitals ; Herbert Williams and Wm. Geo. Willoughby, St. Bartholomew's Hospital.

Second Division.—Frank Richardson BlaxaKM, University College ; Arthur Thos. Brown, Guy’s Hospital; Edward Vipont Brown, St. Bartholomew's Hospital; Henry Edwad. Leigh Canney, University College ; Herbert Edmund Cuff, Guy’s Hospital; Horace Duncan, St. Thomas’s Hospital and Camb.; Frederick Edge, B.Sc., Owens College and Manchester Royal Infirmary ; Harry William Elphick, University College ; Arthur Grayling, St. George's Hospital ; Edwin Birchall Hastings, University College ; John Sydney Hicks, London Hospital ; Arthur Hill Joseph, Bristol Medical School and King’s College ; George Herbert Lang, University College and Manchester Royal Infirmary ; Arthur Nicholas Little, Bristol Medical School ; Isabella Macdonald Macdonald, London School of Medicine and Royal Free Hospital ; Brian Melland, Owens College and Manchester Royal ; Enoch Moss, Guy's Hospital; Patrick Moriarty

2050 Tue LANCET,)

MEDICAL NEWS.

(Nov. 24, 1888,

O'Brien, College, Live 1; Charles P. Oliver, cross Hospital; Philip Nicholas dall, Guy Bellingham Smith, Thomas W. Smith, Guy’s Hospital ; Geo. W. Sutherland, B.A. Syd., University College, London, and Univ. Edinb.; Henry Symonds, St. Bartholomew's Hospital ; Chas. Henry Taylor, King’s College ; Stuart Alex. Tidey, St. Mary's Hospital; Wm. Elliot Tresidder, Guy's Hospital ; ncis W. Tunnicliffe, St. Bartholomew's Hos-

ital; Helen Webb, London School of Medicine and Royal Free ospital ; Ernest Wills, University College; Chas. Wilson, London

Hospital.

Lapy DvuFFERIN’s FunpD.—A Zenana hospital was opened on the 2nd inst. at Quetta in Beloochistan.

THE memorial stone of the Blackheath and Charlton Cottage Hospital was laid on the 10th inst. by Lady Maryon- Wilson.

THE widow and family of the late Mr. G. W. Petter ropose to endow to his memory a ward in the North Devon nfirmary with £100 a year. The deceased was a native of

Barnstaple.

QUEEN’s COLLEGE, CorK.—The following gentle- men have been awarded scholarships in the Faculty of Medicine :—Third year : James B. Moore, Michael Toomey; exhibitioners, E. V. Eames, Martin J. D’Arcy. Fourth year: Anatomy, Physiology, and Surgery—John Hennessy.

THe New WaATER-SUPPLY, LIVERPOOL. — The Chairman (Alderman Bower) stated at the meeting of the Water Committee held on Monday that the works at Vyrnwy were approaching the point of impounding the water, and the advantages of their many years of work would now be seen.

Sr. GeorGce’s Hospitar.—The following scholar- ships have been recently awarded :—£125 Scholarship, open to the sons of medical men, to Mr. A. Russell Rendle ; £65 —— for Cambridge men who have passed the 2nd M.B., to Mr. G. E. Hale; £50 Scholarship, open, to Mr. E. Little.

ProposED THAMES PRESERVATION Socrery.—In view of the constant attempts made by riverside towns on the Thames to drain down to the river, we understand that ‘it is in contemplation to organise a Thames Preservation Society, to consist of all riparian owners and all residents in the metropolis who desire that the river shall be main- tained, not only free from contamination as regards the water, but also that the air should be pure likewise. The objects of the Society will be to watch every attempt to injure the river as a health resort.

THe SANITARY INsTITUTE.—At an examination held on Nov. 8th and 9th, seventy-four candidates presented themselves—fifteen as local surveyors, and fifty-nine as imspectors of nuisances. Of the former class six, and of the latter thirty-one, were certified to be competent to discharge the duties of their respective offices.—At a meeting of the Council of the Institute, held on the 14th inst., Sir Douglas Galton, K.C.B., F.R.S., in the chair, Earl Fortescue, Dr. B. W. Richardson, F.R.S., Sir T. Spencer Wells, and eleven other members and Associates, were enrolled, and further applications were read.

GENERAL HospiraL, Croypon.—Sir Thomas Edridge presided at the annual meeting of the governors, held at the Town Hall last week. The report of the com- mittee of management stated that 7450 cases had been treated during the year, an excess on the previous year of 626. The financial statement, compared with that of 1887, exhibits a falling off in the receipts from annual subscrip- tions and the’ Hospital Sunday and Saturday collections. During the year several legacies were received, and thus the income of the hospital had been maintained. The total of the invested funds is now £11,113 9s. 9d.

BeQUESTS AND DoNaTIons To Hosprrats.—The late Mr. James Brown McCulloch, of Dechmont Lodge, Bothwell, has bequeathed to the Royal Infirmary, and Western Intirmary, Glasgow, £500 each.—The Tong Street Concert Committee has handed over to the Joint Hospital Fund, Bradford, £35 5s. 5d., the proceeds of a recent concert. —A bazaar held at Trentham in July last, on behalf of the Children’s Hospital, North Statfordshire, produced £23 4s. 9d.—Miss Hewitt has given £200 in liquidation of last year's deficiency on the funds of the Lytham Cottage Hospital, and also for providing funds for the complete re- painting and redecorating the institution and other excep- tional outlay.—Mr. Gervas Taylor has given £50 to the Meath Hospital, Dublin

Miptanpd Socrery. — The meeting of this Society was held at the Grand Hotel, Birmingham, on Wednesday, Nov. 14th, when an address on ‘Plastic Surgery” was delivered by Sir William Mac Cormac. The president, Mr. Hugh Ker, occupied the chair, and there was a large attendance of membe and others from all parts of the Midlands.

NortH STAFFORDSHIRE InFrRMARY.—Mr. B. Udall presided at the annual meeting of this institution, held on the 15th inst. The income for the year had been £9759, against £8838 in the previous twelve months. The ordinary expenditure had been £8753. From the report of the trustees of Sir Smith Child’s North Staffordshire Con- valescent and Incurables Fund, it appears that 87 patients, against 122 last year, had been sent to the convalescent institutions during the year.

CARNARVONSHIRE AND ANGLESEY INFIRMARY.— The governors of this institution held their annual meeting on the 8thinst. The statement of accounts was read by the secretary, and showed that the total ~ ¢ for the year were £884 14s. 2d., a decrease of £117 4s. 3d. upon 1887. The expenditure was £807 17s. 6d., a slight increase on the

revious year. The sum of £895 13s. 6d. had been received rom the committee of the Penrhyn Memorial Fund, and expended on the building. The medical report stated that 1311 out-patients and 59 in-patients were admitted during the year—a decrease, respectively, of 344 and of 10 on last year. SANITARY RESPONSIBILITY OF TENANTS.—At the instance of the sanitary inspector of the burgh, thirty householders were prosecuted on the 2nd instant, at a special diet of the Coatbridge Police-court, for allowing the courts, areas, and conveniences which they use and have access to remain in a dirty and unwholesome condition. The defendants, without exception, denied the charge, and con- tended it was not their duty to keep the place clean, and, if it were, it was impossible, as it was a public court. But, as was pointed out, according to the Act of Parliament, it is the duty of the tenant, and not the landlord, to keep the premises clean. The defendants were fined 5s. each, and ordered to keep the court clean.

UNIVERSITY OF BrRuUSSELS.—At the examination for the M.D. degree, which commenced on the 6th inst., eleven candidates presented themselves, of whom six failed to satisfy the examiners, and the following five were admitted to the degree :—l. Jehangir J. Cursetji, L.M. and 8. (Bomb. Univ.), L.R.C.S., L.R.C.P., L.M. Edin., L.F.P.S. Glasg., of Bombay. With at distinction. 2. John Girling, M.R.C.S. Eng., L.R.C.P. Lond., L.S.A., of York. Wi distinction. 3. Alexander L. Achard, M.R.C.S. Eng., L.R.C.P. Lond., L.S.A., of London. 4. William Habgood, M.R.C.S. Eng., L.R.C.P. Lond., L.S.A., of London. 5. Edgar Powell, M.R.C.S. Eng., L.R.C.P. Lond., of London.

Socrery oF MepicaL OrFicers oF HEALTH.—A special meeting of the Birmingham and Midland branch of ae shows Society was held on Thursday, Nov. 8th, at the Council House, Birmingham, to consider the subject of tenure of office of medical officers of health. There were pre- sent Dr. B. Hill (Birmingham), Dr. A. Hill (Birmingham), Dr. Fenton (Coventry), Mr. H. May (Aston), Mr. Perks (Burton-on-Trent), Dr. Page (Redditch), hon. sec., and others. The immediate cause of the meeting was the great injustice that had recently been perpetrated at Ruthin in the case of Dr. Lloyd Roberts, who had held the office of medical officer of health for twelve years, during which time no complaint was laid against him. He resigned for the technical purpose of allowing his authority to acquire of his salary (£25) from the | Pos’ Government Board, fully expecting to be re-elected, when the Town Council turned round and elected a local man. After some discus- sion on the injustice of the present method of tenure of office and the public health an —— 1 of the above case, on the motion of the President (Dr. B. Hill), seconded by Dr. Page (hon. sec.), the following resolu- tions were unanimously carried :—‘‘1. That the Birming- ham and Midland Branch of the Society of Medical Officers of Health desires to call the attention of the Local Government Board to the case of Dr. Lloyd Roberts, and, at the same time, to express the hope that the Board may in the near future use its influence to Ye security of tenure of office to medical officers of health. 2. That this

THE LANCET,)

MEDICAL NOTES IN PARLIAMENT.—APPOINTMENTS. [Nov. 24, 1888. 1051

Branch considers that, from the fact that the resignation of Dr. Lloyd Roberts’ long tenure of office was only for a technical purpose, no other medical man should have applied for the post, and that such application on the part of Dr. Davies Jones is a breach of professional ethics. 3. That these resolutions be communicated to Drs. Lloyd Roberts and Davies Jones, THE LANCET, the British Medical Journal, the Denbighshire Free Press, and the Birmingham papers. ”

MANCHESTER AND SALFORD MEDICAL CHARITIES. The annual meeting of the subscribers to these charities was held on the 19th inst., when the committee presented a favourable report of the work done during the past year. The total sum raised this year was £8019, as against £7770 collected in the preceding twelve months. During the past nineteen years the sum of £138,227 had been raised for the local hospitals and dispensaries through this movement. At the conclusion of the meeting it was announced by the secretary that ihe collections in 1889 would be made on the following dates :—Hospital Sunday, February 10th; Hospital Saturday, February 16th.

CHARING-CROSS HosprraL.—The triennial festival dinner of this hospital was held in the Whitehall Rooms of the Hétel Métropole on Wednesday, the 21st inst. The Right Hon. the Earl of} Derby, K.G., was in the chair, and besides most of the members of the staff of the hospital many of those interested in its success were present, to the number of 180. After giving the usual toasts of the ‘‘Queen and the Prince and the Princess of Wales,” the Chairman proposed the “Army, Navy, and Reserve Forces,” to which Lieut.- General Sir R. Biddulph and Captain Probyn replied, the latter referring to the services which had been rendered to the Volunteer organisation by a former member of the Charing-cross staff, Mr. Cantlie. The Chairman proposed the toast of the evening, ‘‘Prosperity to Charing-cross Hospital,” and mentioned improvements which had been made in the building during the past three years-—viz., the opening of a special accident ward, the children’s ward, and new operating theatre. He also referred to the en- largement of the medical school, rendered necessary by the increase in the number of students, and to the change in the nursing arrangements now being carried out in the hospital. The receipt of subscriptions and donations to the extent of £3250 was announced for the evening. The treasurer of the hospital, Mr. John B. Martin, replied. Mr. Robt. Stewart proposed the ‘‘ Medical Staff,” to which Dr. A. J. Pollock, the senior physician, replied.

=

MEDICAL NOTES IN PARLIAMENT.

The Committee on Sweating. In the House of Lords on the 20th inst., Earl Brownlow was added to this Select Committee. Infant Mortality.

In the House of Commons on Thursday, the 15th inst., Mr. Picton asked the President of the Local Government Board if he could give any further information as to the probable date of the issue of the Depart- mental Report on Infant Mortality, which was stated to be in the printer's hands early in July.—Mr. Ritchie said he was afraid he could not give the hon. gentleman a very satisfactory answer. It was true the report was in the hands of the printers early last July, but after being printed it had to undergo very careful revision, which, on account of the tables and tigures, was a prolonged ——— The revision was not yet es but it was Saere proceed with as rapidly as possible, and he hoped the report would be issued without undue delay.

Broadmoor Criminal Lunatic Asylum.

On the vote of 232,802 for the Broadmoor Criminal Lunatic Asylum Mr. Labouchere expressed his gratification that this vote was uced from £36,549 ; but still the asylum was, he said, a nest of jobbery, as was shown by the fact that there were 151 officials to look after 541 criminal lunatics. The chaplain was paid £400, and also received £390 retired pay as an ex-chaplain and instructor in the sa Farquharson

d the inmates required extra supervision both as criminals and as lunatics. In this asylum there was a good deal of valuable clinical material wholly neglected. The connexion of crime with lunacy might be studied with advantage.—Mr. Stuart Wortley said there was an independent board of unpaid managers, and the Lunacy Commissioners always reported favourably upon the management of this asylum. The Committee divided, and the numbers were—for the amendment, 80; against, 177 ; majority, 97. The vote was then agreed to.

Typhoid Fever in Dublin Barracks.

On the 20th inst., Mr. Stanhope, in answer to Mr. Addison, said that four officers had been ill from enteric fever, believed to have been con- tracted in Dublin Barracks, but only one had died. There were serious difficulties in these barracks as to the disposal of the sewage, which difficulties could scarcely be overcome until the sewage arrangements of the —— improved. The sanitary state of the Royal and Welli nm Barracks was a source of great anxiety, and he had dete: to

institute a wholly independent inquiry into it.—Mr. oo inquired whether reforms would not be extended to all barracks.—Mr. Stanh: thought it desirable that all barracks should be included ; but he w like first of all to get the most important cases.

Bow-road Cemetery.

Mr. Matthews informed Mr. Cunninghame-Graham that irregularities in this case had not been sufficiently brought home to warranta —., tion, but the inspector had been ordered to satisfy himself t the orders in council were obeyed in all particulars.

Pieuro-pneumonia.

Lord Lewisham, in answer to Dr. Farquharson, said that quarantine was rejected by the Departmental Committee on this subject, and that the travelling inspectors were directed to use their best endeavours to trace the origin of any outbreak. Compensation could only be given with the sanction of Parliament.

Surgeons employed on Mail Steamers.

On Thursday, Mr. Richard Power asked the Postmaster-General whether he had issued written instructions to the Orient and the Peninsular and Oriental Companies, carrying Her Majesty's mails under contract to Australia, directing that no surgeons shall be employed on the mail steamers who are not firstapproved by him, and that their age shall not be less than twenty-three or more than —_— years. Ifhe state how the oo and qualifications of the surgeon affect the proper carriage and custody of the mails. What benefit the travelling public will derive from a rule providing that the surgeons on mail steamers shall not be more than thirty years of age. And whether he has issued the same instructions to other Magee mail companies ; and, if not, can he explain for what reason. —The Postmaster-General, in reply. said the con- tracts recently entered into between the Post-office and the two com- panies mentioned by the hon. member require them to carry, as a of their ship’s complement, a competent surgeon, who, according to the usual custom in such cases, is appointed subject to the approval of the Postmaster-General. This approval is given under certain long-estab- lished conditionsas to fitness, and he found that those conditions were communicated to the Orient Company on the commencement of their contract in February last. The other company, being old conti were alreagly aware of the Post-office regulations on point. One the conditions laid down is, that the candidate for employment as surgeon shall not be less than twenty-three years of age, nor more than thirty years of age. The rule is a general one, and was not laid down with reference to any particular contract. He apprehended that any arrangement affecting the health and efficiency of the ship's compan: affected the proper carriage and custody of the mails.—Dr. Clarke said he should like to know whether the Postmaster-General intended to carry out the rule, and if he thought that medical men over thirty years of age were incompetent to carry out the duties. Would he give us some reasons why the Post-office had laid down this rule, and wh they thought that thirty years of age was a period after which a medi man was not able to practise his profession in order to keep the crew of a ship in health.—The Postmaster-General said he did not see any reason to depart from the rule laid down.—Dr. Clarke said that on the estimate he would raise this question, and move the reduction of the Postmaster-General's salary.

The Royal College of Surgeons and the Supplemental Charter.

On Monday next Lord Randolph Churchill will ask the First Lord of the Treasury whether he will lay upon the table a copy of the statements made by the deputation of the Members of the Royal College of Surgeons of England to the Lord President of the Council on Nov. 11th, 1887, upon the subject of the supplemental charter since granted to the said 2.

by

and of all doe ts and cor relating lodged in Privy Council Office, including the petition to Her Majesty, signed 4665 members of the College.

Appointments,

Succesgful applicants Vacancies, Secretaries of Public Institutions, and others possess oe suitable for this column are invited to Sorward it to tue LANCET Office, directed to the Sub-Editor, not later than 9 o'clock on the Thursday morning of each week for publication in the next number. ALLINGHAM, HERBERT WM., F.R.C.S., Surgeon to the Great Northern Central Hospital, and Demonstrator of Anatomy at St. George's Hospital, has been appointed Assistant Surgeon to St. Mark’s Hospital for Fistula.

Drake, J. H., L.R.C.P., L.R.C.S.Edin., L.F.P.S.Glasg., has been appointed Medical Officer of the Halberton District, Tiverton Union.

GoopsaLL, D. H., F.R.C.S., late Hon. Assistant Su m to St. Mark’s Hospital for Fistula, has been appointed Hon. Surgeon, vice William Allingham, F.R.C.S. resigned.

Jacop, E. L., B.A.Lond., M.R.C.S., L.S.A., has been reappointed Medical Officer of Health, Surrey United Sanitary District.

Kite, Epwin W. D., M.B. Dur., M.R.C.S., L.S.A., has been appointed Obstetric and Ophthalmic House Surgeon to the Queen’s ~ Birmingham, vice J. J. Blurton, M.B. Dur., M.R.C.S., f

LEIGH, RANDLE, B.Sc.(Lond.), M.R.C.S., has been Chloro- formist fo the Liverpool Royal Infirmary, vice A. W. Collins, M.B., M.R.C.S., resigned.

MorRIs, CHARLES ARTHUR, M.B., B.Ch., has been appointed Pathologist to the Chelsea Hospital for Women, vice Dr. Burnet, resigned.

Parker, T. R. B., M.D.Univ. St. And., M.R.C.S., L.S.A., has been appointed Medical Officer of the 9th District, Croydon Union.

PEARSE, FRANK, L.R.C.P.Edin., M.R.C.S., has been appointed Medical Officer of the Colyton District, Axminster Union.

Priest, J. DAMER, M.R.C.S., L.S.A., has been rea) nted Medical Officer of Health for the Urban Sanitary District of Waltham Holy

Cross.

WHEATLEY, JAMES, M.B., B.S.(Lond.), has been appointed Senior House —— to the Blackburn and East Lancashire Infirmary, vice G. T. Gifford, M.R.C.S., resigned.

Yarr, M. T., L.R.C.S.Irel., L.M.K.Q.C.P. rE yo Staff), has been go Acti Superintendent of Government Civil Hospital, Hong-Kong, China, vice C. J. Wharry, reti

1052 THe LANCcET,)

VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS.

[Nov. 24, 1888.

Vacancies,

in compliance with the desire Seumen numerous subscribers, it has been decided to resume the publication under this head of brief particulars of the various Vacancies which are announced in our advertising columns. For further information regarding each vacancy reference should be made to the advertisement. ——

BIRMINGHAM AND MIDLAND FREE HOSPITAL FOR SICK CHILDREN.— Acting Surgeon.

BLACKBURN AND EAST LANCASHIRE INFIRMARY. —Junior House Surgeon. Salary £30 per annum, with board, and |

AsyLuM, Birmingham.—Resident Clinical without salary.

BOROUGH OF BRADFORD FEVER HospiTaL.—Resident Medical Super- intendent. Salary £150 per annum, with rd and residence.

CHELSEA HOSPITAL FOR WOMEN, Fulham-road, London, 8.W.—Three —— al Assistants. The fee is three guineas for a period of three months.

HOLLOWAY SANATORIUM HOSPITAL FOR THE INSANE, Virginia Water.— Senior Assistant Medical Officer. Salary £250, with board, lodging, and washing. Also a Junior Assistant Medical’ Officer. Salary £120, with board, lodging, and washing.

Hospital FOR SICK CHILDREN, Great Ormond-street, London, W.C.— Surgeon. Also an Assistant Surgeon.

LonpoNn Lock HospPitaL.—Surgeon to the Out-patients.

LONDON TEMPERANCE HospitaL, Hampstead-road, N.W. — Registrar and Chloroformist. Salary £50 per annum.

Lonpon THROAT Hospital, 204, Great Portland-street, W.—House Surgeon,

LUTON FRIENDLY Societies’ MepIcAL INsTITUTE.—Medical Officer. Salary £200 per annum, with residence.

NORTH-EASTERN HoOspitaL FOR CHILDREN, Hackney-road, E.—Junior House Surgeon. Salary £30.

Roya. Hants County Hospita, Winchester.—House Surgeon. Salary £100 per annum, with board and lodging.

ROYAL Soutu LONDON DIsSPENSARY, St. Geerge’s-cross, Lambeth, S.E.— Surgeon to the Walworth District. Honorarium £20 per annum.

STAFFORDSHIRE GENERAL INFIRMARY, —Assistant to the House Surgeon No salary, but board and lodging.

SUNDERLAND INFIRMARY.-—-House Physician. Salary £80, rising £10 annually to £100, with board and residence.

THE SAMANA AND SANTIAGO RAILWAY COMPANY, 175, West George- street, Glasgow.—Medical Officer to the Company at Sanchez, Bay of Samana, Santo Domingo. Salary £200 per annum, with residence and expenses paid to destination. “Eng: agement for two years.

UNIVERSITY OF EDINBURGH. — Examiner in Medical Jurisprudence. Salary £75 a year, with an allowance of £10 a year for travelling and other expenses, in the case of an Examiner not resident in Edinburgh.

WESTMINSTER Hospital, Broad Sanctuary, Westminster, S.W. — Curator.

Births, Marriages, and Deaths,

BIRTHS.

ApaM.—On the 15th inst., at Malling Place, West Malling, Kent, the wife of James Adam, M.D., of a son.

CLARK.—On the 14th inst., at Rahere, Brunswick-road, Gloucester, the wife of Oscar Clark, M.A., M.B. Oxon., of a daughter.

Ganpy.—On the 10th inst., at the Hill Top, U pper Norwood, the wife of W. Gandy, M.R.C.S. , of a son (stillborn).

Har.ock.—On the 16th’ inst., at Singleton, Sussex, the wife of Harry Harlock, L.R.C.P. Lond., M.R.C.S. , of a daughter.

SmyTH.—On the 13th inst., at Castleac re, Adelaide- -road, Brockley, 8.E., the wife of F. Sydney Smyth, F.R.C.S., of a son.

WALKER.—On the i8th inst., at Stalham, Norfolk, the wife of Norman Hendrie Walker, M.B., ofa daughter.

MARRIAGES. HuMPHRY—ATHERTON.—On the 2nd ult., at Cliftonville, Mackay, Queensland, Ernest ——, M.R.C.S., L.R.C.P., of Townsville, Queensland, eldest son of Frederick A. Humphry, F.R.C.S. , Marine-

| a Brighton, to Adelaide M. Atherton, eldest daughter of Jdmund Atherton, of Cliftonville, Mackay, Queensland. LEIGH—WALEs.—On ‘the 20th inst., at St. tdmund’s, Downham,

Norfolk, by the Rev. A. 8. Latter, assisted by the Rev. Canon Beechey, A. H. ~y ~ of Shortlands, Kent, to Edith Mary, eldest daughter of Thos. Garneys Wales, of Downham. SINGLETON—PHILLIPS.—On Sept. 20th, at Trinity Church, Adelaide, hy the Rev. R. Reid, Francis Elliot-Corbet Singleton, L.R.C. P., L.R.C.S. Edin., P brn son of the late Francis Corbet Sin let ton, of fy ed to Edith Margaret, third daughter of James Phillips,

DEATHS.

pe inst., at Eye, Northamptonshire, John Beecroft,

Butts.—On the eh” inst., at the residence of his son-in- law, Vaynor House, Breconshire, Harry Grosvenor Butts, M.D., of The Drill, and Georgetown, Demerara, aged 63.

Jackson.—On the 19th inst., at Jesmond, Edward Jackson, M.B. Lond., M.R.C.S., aged 62.

O’MEARA.—On the 16th inst., at Sutton Bridge, Lincolnshire, John Brett Johnstone O'Meara, L.R.C.P. E., L.R.C.S.E., youngest son of ped late Rev. Eugene O'Meara, Rector of Newcastle, . Dublin, ag

NB—A ia the Insertion foe of 5. ia charged for the of Notices of Births,

Medical Diary for the ensuing Geek,

Monday, November 26.

RoyaL LonpDON OPHTHALMIC HOSPITAL, MOORFIELDS. — Operations daily at 10 A.M.

RoyaL WESTMINSTER OPHTHALMIC HospitaL.—Operations, 1.30 P.M., and each day at the same hour.

CHELSEA HOSPITAL FOR WOMEN.—Operations, 2.30 P.M. ; Thursday, 2.30.

St. MarRk’s HospitaL.—Operations, 2 P.M. ; Tuesday, 2.30 P.M.

HOSPITAL FOR WOMEN, SOHO-SQUARE. — Operations, 2 P.M., and on Thursday at the same hour.

METROPOLITAN FREE HospitaL.—Operations, 2 P.M.

Royal ORTHOPEDIC HosPiTaL.—Operations, 2 P.M.

CENTRAL LONDON OPHTHALMIC HOSPITAL. — Operations, 2 P.M., and each day in the week at the same hour.

Society or ARTS.—8 P.M. Capt. W. de W. Abney: Light and Colour. (Cantor Lecture.)

MEDICAL Society OF LONDON.—8.30 P.M. Mr. George Stoker: Ona case of Goitre, illustrating a Theory in reference to the Function of the Thyroid Gland. —Mr. J. Astley Bloxam: Two cases after Excision of Goitre.—Dr. Beevor: Case of Polio-myelitis from Injury.—Dr. Hadden : Case of Neuro-muscular Irritability.—Mr. H. Allingham: Case of Resection of Inferior Maxillary Joint for Ankylosis.—Dr. Campbell: A case of Erythema Gangrenosum.— Mr. A. B. Barrow: Case of Ectopia Vesice after Operation. And other cases.

Tuesday, November 27.

Guy’s Hosp1TaL.—Operations, 1.30 P.M., and on Friday at the same hour. Ophthalmic Operations on Monday at 1.30 and Thursday at 2 P.M.

St. THomas’s HospitaL.—Ophthalmic Operations, 4 P.M. ; Friday, 2 P.M.

CANCER HOSPITAL, BROMPTON.—Operations, 2 P.M. ; Saturday, 2 P.M.

WESTMINSTER HOsPITAL.—Operations, 2 P.M.

WEsT LONDON HospiItaL.—Operations, 2.30 P.M.

St. Mary’s HosprTaL.—Operations, 1.30 P.M. Consultations, Monday, 2.30 P.M. Skin Department, Monday and Thursday, 9.30 a.M. Throat Department, Tuesdays and Fridays, 1.30 P.M.

ANTHROPOLOGICAL INSTITUTE OF GT. BRITAIN AND IRELAND.—8.30 P.M. The President will exhibit a Gold Breastplate from an Ancient Peruvian Grave. Rev. Benjamin Danks: Marriage Customs of the New Britain Group.—Mr. Osbert H. Howarth: The Survival of Corporal Penance.

RoyaL MEDICAL AND CHIRURGICAL SOCIETY.--8.30 P.M. Dr. William Robert Smith : The Etiology of Puerperal Fever.—Dr. Samuel West : Acetonuria and its Relation to Diabetic Coma.

Wednesday, November 28.

NATIONAL ORTHOPEDIC HosPiTaL.—Operations, 10 A.M.

MIDDLESEX HospitaL.—Operations, 1 P.M.

St. BARTHOLOMEW’S P.M. ; Saturday same hour. Ophthalmic Operations, Tuesday and Thursday, 1.30 P.M. Surgical Consultations, Thursday, 1.30 P.M.

St. THomas’s HospiTaL.—Operations, 1.30 P.M. ; Saturday, same hour.

LonpDoN HosPiTaL.—Operations, 2 P.M. ; Thursday & Saturday, same hour.

GREaT NORTHERN CENTRAL HOSPITAL.—Operations, 2 P.M.

SAMARITAN FREE HOSPITAL FOR WOMEN AND CHILDREN.—Operations, 2.30 P.M.

UNIVERSITY COLLEGE Hospitat.—Operations, 2 P.M. ; Saturday, 2 P.M. Skin Department, 1.45 P.M. ; Saturday, 9.15 A.M.

ROYAL FREE HosPitat.—Operations, 2 P.M., and on Saturday.

CoLLEGE HospiTaL.—Operations, 3 to 4 P.M. ; Friday, 2 P.M. Saturday, 1 P.M.

CHILDREN’S HOSPITAL, GREAT ORMOND-STREET.

Surgical visits on Wednesday and Saturday at 9.15 a.M.

HUNTERIAN SOCIETY.—8 P.M. Dr. Davies: A case of Tumour of the Tongue.—Mr. Jonathan Hutchinson : Affections allied to Raynaud’s Disease.

RoyAL MICROSCOPICAL SOCIETY.—8 P.M.

Society OF ARTS.—8 P.M. Col. G d: Th

BRITISH GYNECOLOGICAL SOCIETY. — 8.30 “y M. Specimens will be exhibited by the President, Dr. Granville Bantock, Dr. Mansell Moullin, and others. Dr. James Oliver: Encysted Serous Peri- tonitis (pelvic in origin). Council 8 P.M.

9.30 A.M. 5

Thursday, November 29.

St. GEoRGE’s HosprTaL.—Operations, 1 P.M. Surgical Wednesday, 1.30 P.M. Ophthalmic Operations, Friday, 1.30 F.M. CHARING-CROSS HOSPITAL.—Operations, 2 F.M.

Friday, November 30. SouTH LONDON OPHTHALMIC HosPiTaL.—Operations, 2 P.M.

Saturday, December 1 MIDDLESEX HOSPITAL.—Operations, 2 P.M.

THE LANCET,]

NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. _[Nov. 24, 1888. 1053

METEOROLOGICAL READINGS. (Taken daily at 8.30 a.m. by Steward’s Instruments. )

THE LANCET Office, November 22nd, 1888.

uc on ia | mum in. n-

Date. | Bulb. Bulb, in Temp. Temp) fall. |” | +| Vaeuo. j

Nov.16 | 30°08 |S.W.| 59 | 57 61 | 52 | 05 | Overcast 30°08 |N.W. 51 47 | 80 | 56 | 39] .. | Raining » 30°02 | 50 | 49 | | 55 | 46 | 05 | Cloudy » 19} 2095 | W. | 54 | 51 | 61 | 56 | 50} Cloudy 20] 2976 IN.W.' 46 | 45 | 79 | 51 | 45 | 11 | Cloudy » 21] 3013 |N.W. 44] ar | .. | ot | 41] .. | Bright

Overcast

Hotes, Short Comments, & Anshers to Correspondents,

It is especially requested that early intelligence of local events having a medical interest, or which it 1s desirable to bring — fies notice of the profession, may be sent direct to

is Office. .

All communications relating to the editorial business of the journal must be addressed ‘‘ To the Editors.”

Lectures, original articles, and reports should be written on one side only of the paper.

Letters, whether intended for insertion or for private in- Jormation, must be authenticated by the names and addresses of their writers, not necessarily for publication.

prescribe or recommend practitioners.

ocal papers containing reports cr news paragraphs should be marked and por the Sub-

Letters relating to the publication, sale, and advertisi departments of THE LANCET to be addressed ‘‘to tie Publisher.”

We cannot undertake to return MSS. not used.

THE VIRTUES AND REMUNERATION OF ASSISTANTS.

Janus.—Our correspondent is very much exercised with an advertise- ment in which a principal wanted an assistant with a great combina- tion of virtues—experience, gentlemanliness, Protestantism, total abstinence, churchmanship, power to dispense, to keep books, ability to attend “a little midwifery,” to ride, to number thirty years—for the modest sum of £30 a year, in-door, as a commencing salary. We must admit that half of these virtues would be ill requited with twice the salary mentioned. And we are persuaded that it is good policy to pay assistants well. But the times have been hard, and we should have to know more of the res domi of the principal himself before being too severe on his advertisement.

Enquirer.—It is neither customary nor legal to charge for such certificate. J. B. should consult his medical attendant. P. H. W.—They are sufficient.

“THE METROPOLITAN HOSPITAL.”—A CORRECTION. To the Editors of THE LANCET.

Srrs,—Permit me to make a correction in my last week’s letter, and voluntarily express regret for making a statement which is not entirely accurate. The sentence “ by underselling it in every item of payment” would be more accurately expressed thus: ‘‘By the adoption of a generally lower scale of comparative charges.” This correction but does not, however, vitally affect, my contention.

Iam, Sirs, yours faithfully, Dalston, Nov. 19th, 1888. FREDK. E. COCKELL, jun., M.R.C.S.

CANCER. To the Editors of THE LANCET.

Srrs,—I shall be obliged if any of your readers can give me informa- tion on the question as to the extent to which Jews are more free from cancer than their fellow men? That they do not enjoy an entire immunity from it I can well believe, but am not aware of the limit or proportion of such immunity as they do appear to possess. Is it at all believed that their abstinence from pork has any influence upon this peculiarity? Iam, Sirs, yours faithfully,

Nov. 15th, 1888. P. J.

MYOMA OF THE UTERUS. To the Editors of THE LANCET.

Srrs,—In the report of the November meeting of the Obstetrical Society of London, published in THE Lancet of Nov. 17th, I note an ¢rror, due to myself, the reporter. In reply to Dr. Herman, I did not say that “the smallest interstitial fibroids were the purest jibromata,” as appeared in the above report. I said the smallest fibroids were the purest myomata. I am, Sirs, yours truly,

Granville-place, W., Nov. 17th, 1888. ALBAN DORAN.

DISEASES AMONGST WORKERS IN A RIFLE FACTORY.

Dr. T. SPASskKI, District Medical Officer of Ijlbski, in Russia, a locality where there is a large firearm manufactory, has published some elaborate observations on the effects of the various kinds of work on the employés. He found two classes of disease especially prevalent— intermittent fever and chest affections, especially phthisis. The first class constituted 18 per cent. of the total sickness, and the second 12 percent. It was also noticeable that fever occurred principally among the women, and phthisis chiefly amongst the men. Plans and elevations are given by Dr. Spasski, which show that the workshops are raised above the level of the ground, which is damp and malarious. The men working in them are therefore less subjected than their wives,

* who remain at home in damp cottages, to malarial influences ; while, on the other hand, they are exposed by the nature of their employ- ments to other affections, arising chiefly from the cramped positions of the body and from the dust and small particles which necessarily fly about in the immediate neighbourhood of their work. More than one-third of the operatives suffered from bronchial catarrh, and 14°8 per cent. from phthisis. Amongst this latter class of cases, those who worked amongst dust were affected twice as much as those who were engaged in more cleanly occupations, the metal and mineral dust proving much more hurtful than wood dust. Those who worked with the file and at the grindstone were especially affected. The author presents charts showing the effect of the different kinds of work on the stature and chest measurement of the workmen. The chest seems to be especially narrow and small amongst the locksmiths who have much filing, the average difference at various ages between their chest measurement and that of the firemen being about three milli- metres.

Mr. Plimmer’s communication has been received. Mr. Foulerton (Chatham).—Next week.

CIRCUMCISION. To the Editors of THE LANCET.

Srrs,—As there is usually a great deal of trouble in the dressing after a circumcision in a child, perhaps a description of the method I have lately adopted and found very successful may be of use te some of your readers, should you think it worth inserting in your widely read journal.

I pass a director under the prepuce as far as the corona glandis, and then pass a pointed curved bistoury along it, and divide the prepuce ; then cut off the two triangular flaps thus formed, dividing the skin and mucous membrane together. All bleeding points are stopped by torsion. I use no sutures whatever, the skin and mucous membrane uniting quite well without any. I then guard the penis by a wire guard, similar to a vaccination shield, ‘but larger and three-cornered, one corner passing under the scrotum, and the base being upwards. There is a tape attached to each upper corner to tie round the waist, and double tapes at the lower corner to tie round each leg. I use no dressing, but car- bolised oil painted on the wound with a camel hair brush The patient gets up the same day, or as soon as he feels quite recovered from the effects of the anesthetic. Iam, Sirs, yours truly,

Ipswich, Nov. 12th, 1888. Jas. NORMAN VOGAN,

“THE PUNCTURE OF A VEIN IN HYPODERMIC MEDICATION.” To the Editors of THE LANCET.

Sirs,—The case related by Mr. Craig Balfour in THE LANceT of Noy. 10th is very interesting. But was the supposed morphia solution tested? The symptoms described resemble more those of some of the other alkaloids of ammonia, or of strychnia ; and it seems unlikely that the mere fact of direct injection into a vein should produce symptoms so unlike those ordinarily exhibited by morphia.

Tam, Sirs, yours truly, Woolwich, Nov. 19th, 1888. SIDNEY Davies, M.A., M.B.Oxon.

PRURITUS. To the Editors of THE LANCET.

Srrs,—Can any fellow practitioner kindly suggest anything reliable in a hitherto intractable case of pruritus vulve associated with eczema of the thigh? The lady is about the climacteric period, and otherwise healthy ; but her sufferings night and day are intolerable, and have been so for months. In vain have been tried solutions of nitrate of silver, ol. menth. pip., ext. conii, sodii hyposulph., hydrarg. bichlor, &c., as also alkaline ointments, quinine ointment, ungt. potass. sulphurata, potass. cyanidi, iodine, &c. I am, Sirs, yours faithfully,

Manchester, Nov. 6th, 1888. M.D.

ARTHRECTOMY vel ARTHROTOMY. To the Editors of THE LANCET.

Srrs,—In your issue of to-day’s date the treatment of joint disease by erasion is fully discussed, Would it not be better to give arthrotomy as a synonym instead of arthrectomy? We have nephrotomy and neph tomy, colotomy and colectomy, and by parity of reasoning arthrotomy is synonymous with erasion, and arthrectomy with excision.

Iam, Sirs, yours obediently, Boundary-rd., N.W., Nov. 17th, 1888. RicHp, NEALE, M.D.Lond.

—

. | | 290 | | our. Dn a m of fter | rom r. H. | for m.— And | | M. | P.M. | day, | iroat P.M. cient f the l of liam rest : same P.M. | hour. | P.M. | P.M. A.M.; f the aud’s | ll be nsell Peri-

1054 Tae LANcET,]

NOTES, COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Nov. 24, 1888,

“HOT MOIST FOMENTATIONS.” To the Editors of THE LANCET.

Srrs,—Dr. Britton’s note on the above in your issue of the 27th ult. reminds me of a “ wrinkle” I got many years ago from a washerwoman whose daughter had peritonitis. It was this. She made a flannel petti- coat hot before the fire, and then folded it. She then ironed it with a

hot flat iron, and again folded it, continuing the process each time until the proper size was obtained. Then she sprinkled the side to go on the skin with boiling water, giving a finaliron. If the thing is done skil- fully, it is too hot to apply, except with care. Advantages: Retains the heat, is light, inexpensive, and clean, and does not damp the clothes, I am, Sirs, yours faithfully,

D.

November, 1888. i. G.

A CORRECTION. To the Editors of THE LANCET.

S1rs,—Allow me to correct an error in your report of the meeting of the Ophthalmological Society on Nov. 8th. In connexion with Mr. Swanzy’s paper I mentioned a case in which conjugate deviation of the eyes to the right had existed during life. Your report runs: “ At the post-mortem it was found that the left internal rectus was absent, the right being exceedingly ill-developed.” Your reporter couid scarcely imagine that defect of both internal recti would explain conjugate deviation. What I really said was: ‘‘At the post-mortem it was found that the right internal rectus was absent, and the left external rectus exceedingly ill-developed.” I am, Sirs, yours faithfully,

Nov. 17th, 1888. J. B. LAWFORD.

A CAUTION. To the Editors of THE LANCET.

Srrs,—I would caution the profession against a man calling himself Dr. Stewart of Inverness, speaking rather broad Scotch, who says he has been a surgeon on board a Liner steamboat, and has been trying to get a situation in London, but now making his way to Portsmouth to his friend, Dr. W——. I find he is a begging-letter impostor and a vagabond, and was had up the other day at Marylebone. He is tall, thin, has fair moustache curled up at each end, and states he is a M.B. and C.M. of Aberdeen or Edinburgh.

Iam, Sirs, yours faithfully,

Godalming, Nov. 20th, 1888. J. F. MILNER.

ROYAL COLLEGE OF SURGEONS OF ENGLAND.

DIPLOMA OF FELLOW.

FIRST EXAMINATION.—ANATOMY AND PHYSIOLOGY. PHYSIOLOGY. Nov. 8th, 1888, from 3 to 6 P.M. (At least three of the four questions must be answered.)

1. State the mode of preparation of and tests for hemoglobin. What are the modifications resulting from the action of acids and alkalies upon it? What is the evidence that bile pigments are related to hemo- globin? 2. Explain the phenomena of the gas interchanges in external and internal respiration. 8. Describe the microscopic structure of the mammary gland, and the modifications which it undergoes ame lac- tation. Name the constituents, organic and inorganic, of milk. What is the origin of the organic constituents? Give the evidence on which

our answer is . 4. Describe the structure of the scala media of the cochlea. What views are held with regard to its functions ?

ANATOMY. November 8th, 1888, from 11 a.M. to 2 P.M. (At least three of the four questions must be answered.)

1. Describe the sixth rib and its costal cartilage ; name the structures attached to, and in relation with, this rib on the left side. 2. Describe the Eustachian tube, giving its direction, connexions, and relations, and its arterial and nervous supply. Give also an account of its develop- ment. 3. Describe the adductor magnus, its attachments, the ar: e- ment of fibres, its relations, nerve supply, and actions. 4. Describe the membranes of the spinal cord, and the means by which the cord is held in its place within the vertebral canal.

SUBSCRIPTION.

Post FREE TO ANY PART OF THE UNITED KINGDOM.

Post Office Orders and Cheques should be addressed to The Publisher, THE LANCET Office, 423, Strand, London, and crossed ‘‘ London and Westminster Bank, St. James’s-square.”

COMMUNICATIONS not noticed in our present number will receive atten- tion in our next.

COMMUNICATIONS, LETTERS, &c., have been received from—Dr. G. H. Savage, London; Dr. Douglas Powell, London; Professor Brown, London; Dr. Whipham, London; Mr. R. Davy, London; Mr. Hare, Manchester; Dr. Bell Taylor, Nottingham; Mr. E. Owen, London ; Dr. H. Shaw, Gloucester; Mr. W. C. Jeffries, London; Mr. John Beckton ; Mr. G. Palmer, Ararat, Vic.; Mr. A. L. J. Smith, New York; Mrs. Willcock, Plymouth ; Mr. Gilroy, Waferbech ; Mr. M. de Meyer, London ; Dr. Hale, Brondesbury ; Mr. Haslam, Birmingham ; Mr. Dagleish, Milton ; Mr. St. Dalmas, Leicester; Mr. J. H. Ashton, Richmond ; Mr. Doran, London; Mr. Twynam, Lydney; Dr. Neale, Hampstead ; Mr. Poland, London; Dr. Edmonds, Aberdeen ; Mr. P. Thornton, London; Mr. Lawford, London; Mr. H. W. Allingham, London; Dr. Heron, London; Mr. Cockell, Dalston; Mr. Smith, Leeds ; Mr. Woakes ; Mr. Gilroy, Dumfries ; Messrs. Richardson and Co., Leicester ; Dr. S. Gibbon, London ; Mr. Corner, London ; Mr. De Gruyther, Leytonstone; Mr. C. Williams, Norwich; Mr. Lawson Tait, Birmingham ; Dr. L. W. Marshall, Nottingham ; Dr. S. Davies, Woolwich ; Mr. Hopkirk, London; Dr. Wallace, Colchester; Mr. F. Pope, Leicester ; Mr. Michelmore, Tiverton ; Mr. Milner, Godalming; Mr. Robinson, Sunderland; Mr. Ford, Devonport; Mr. Laban, West Bromwich ; Dr. Madden, Dublin; Dr. Ridge, Enfield ; Mr. C. D. Roe, London ; Mr. G. A. Wright, Manchester ; Dr. Shroff, Bombay ; Mr. L. Humphry, Cambridge ; Mr. W. O. Travis, London ; Mr. Elliot, Ottery St. Mary; Mr. Croft, London; Surgeon-Major Ince; Messrs. Sharp -and Co., Glasgow ; Mr. Bonsall, Beckley ; Mr. Dessurne ; Mr. White, Haughley; Mr. J. M. Cotterill, Edinburgh ; Messrs. Hopcroft and Co. ; Mr. J. B. Milnes, Dewsbury; W. P.; Observer, Pittsburg; Stoke Newington; Reincrag, Clapham; General Infirmary, Staffs; Leeds General Infirmary ; Climax ; A Senior Assistant Med. Off. in a County Asylum; W., London; J. B., Bournemouth ; Enquirer; Infirmary, Glam. ; Student; Practice, London; A. B.; Liverpool; Principal, Brighton.

LETTERS, each with enclosure, are also acknowledged from—Mr. Day, Sheffield ; Mr. Holt, Lancashire ; Miss Hunt, Dublin; Messrs. Condy and Mitchell, London; Mr. J. Carter, London; Dr. Davies, Ebbw Vale ; Dr. Halpin, Brighton ; Mr. Turner, Hastings ; Messrs. Dawson Bros., Montreal ; Mr. Thompson, Manchester ; Messrs. Rowntree and Co., York ; Mr. Walker, Stalham ; Mr. Barker, London ; Messrs. Stent and Sons, Guildford ; Mr. Heywood, Manchester; Mr. Cockell, West Hartlepool; Mr. Greenwood, Staffs; Dr. Philipps; Messrs. Squire and Son, London; Dr. Taylor, Huddersfield ; Messrs. Godfrey and Cooke, London ; Mr. Thomas, Swansea ; Mr. Foote, Cirencester ; Mr. James, Pontypridd ; Messrs. Warren, Bristol; Messrs. Potter and Clarke, London ; Dr. Robinson, London ; Messrs. Eason and Son, Dublin ; Mr. Christie, Luton; Mr. Gardiner, Dulwich; Virtus, London ; E. P., Bournemouth ; Bristol General Hospital; Springfield House Asylum ; Bristol Dispensary ; Medicus, London; Hon. Sec., Stoke Newington; M.B., Lewisham; H. K., London; Smedley’s Hydropathic Co.; Domum, London; L.S.A., Leeds; Marlboro’, London; Staffs General Infirmary ; G. H. Y.; Urban, London; Alpha, London; The Union, Winchcombe ; R. H. 8., London; Medicus, Margate; Lady Superintendent, Worcester; Dr., London; Cymro, Bristol; Ducker Portable Ho. Co.; C., London; Sirius, London; Surgeon, London ; M.D., Crewe ; Spes, London ; Student, London.

Daily Free Press (Aberdeen), Croydon Advertiser, Herald and Weekly Free Press, Hertfordshire Mercury, Sussex Daily News, Sunderland Daily Echo, Surrey Advertiser, Western Mail, Reading Mercury, Hong Kong Daily Press, Coleraine Chronicle, Evening News (London), Yule Tide (Cassell’s Christmas Annual, 1888 ), Glasgow Herald, Ilustrations, Chemical News, Lady's Pictorial Christmas Number, &c., have been received.

ADVERTISING.

Books and Publications (seven lines and under) Official and eral Announcements Trade and Miscellaneous

Front oe

ecoooeaco

a Page ° An Entire Page .. oe ee oe ee oe os The Publisher cannot hold himself responsible for the return of onials, &c., sent to the office in reply to advertisements; copies only should be forwarded. OTICE.—Advertisers are requested to observe that it is con to the Postal Regulations to receive at Post Offices letters to initials only.

An o

inal and novel feature of “‘ THE Lancet General Advertiser”

is a special Index to Advertisements on page 2, which not only affords a

ready means of finding any notice, but is in itself an additional advertisement. Aavertiooments (to ensure insertion the same week) should be delivered at the Office not later than Wednesday, accompanied by a remittance.

Answers are now received at this Office, by special Terms for Serial Insertions may be obtained of the

arrangement, to Advertisements appearing in THE 4 Publisher, to whom all letters relating to Advertisements or Subscriptions should be

LANCET.

Advertisements are now received at all Messrs. W. H Smith and Son’s Railway Bookstalls throughout the United Kingdom and all othes vertising Agents.

Agent for the Advertisement Department in France—J. ASTIER, 66, Rue Caumartin, Paris.

£0 One Year............ £112 6| Six Months.......... £016 8 al Line TO CHINA AND INDIA Year 1 16 10 To THE CONTINENT, COLONIES, AND UNITED